chain of custodymicromethodslab.com/pdfs/mmlabcoc2017r5.pdfcompany name: project manager: address:...
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Company Name: Project Manager:
Address:
City: State: Zip: Email Address :
Phone:
Fax:
Sampler Name Printed:
Project Name:List Analyses Requested
Sample IdentificationSampling Date/Time
Matrix
Printed Name Signature Company Date Time
Relinquished by
Received by
Relinquished by
Received by
Relinquished by
Received by
Turn Around Time & Reporting
*All rush order requests must be prior approved.
M-M Lab WO #
Chain of Custody RecordPO Box 1410, Ocean Springs, MS 39566-1410 (228) 875-6420 FAX (228) 875-6423
Preservative:
Our normal turn around time is 10 working days__Normal__Next Day*__2nd Day*__Other*______
__Phone__Mail__Fax__Email
www.micromethodslab.com
Purchase Order #:
Sampler Name Signed:
Project #:
# of
Con
tain
ers
QC Level: Level 1 Level 2 Level 3
DCN# F316 Rev.#5
Lab ID# MS00021 LELAP ID # 01960 TNI ID # TNI01397
Gra
b (G
) or
Com
posi
te (C
)
Code
ID# ID# ID# ID#
Field Test Field Test Field Test Field Test W = Water DW = Drinking Water S = Solid SO = Soil SE = Sediment L = Liquid A = Air O = Oil SL = Sludge
Preservation:
Field TestingMatrix:
1= H2SO4 2= H3PO4 3=NaOH 4=ZnC4H10O6 5=ZnC4H10O6 & NaOH 6=HNO3 7=Na2S2O3 8=HCl 9=NaHSO4 By: _____________________________ Date & Time ___________________
Received on Ice? Y N Thermometer#_________ Cooler #_______ Receipt Temp Corrected(ºC) Sample_____Blank_____Cooler_________ **All Temps are Corrected Values**
Physical Address: 6500 Sunplex Drive, Ocean Springs MS 39564
Notes:
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