Drinking Water Bacteriological Sample Chain of Custody Form
System Name
PWSID Number
Sample Location
Date Collected
Time Collected
Collected By
Sample Type
Sample ID
Transit Temperature (°C)
Parameter
Test Requested
Total Coliform/E. coli (Presence/Absence)
Heterotrophic Plate Count (HPC)
Other
Relinquished By (Printed Name)
Signature
Date/Time
Received By (Printed Name)
Signature
Date/Time
Date/Time of Delivery to Laboratory
Laboratory Sample ID
Laboratory Comments