CHAIN-OF-CUSTODY RECORD The Proponent of This Form is the Directorate of Laboratory Sciences
SAMPLE PARAMETER INSTALLATION _____________________________ PROJECT NO. __________________ PROJECT OFFICER _________________________________________________________ PACKED BY ________________________________________________________________ # NOTE: For use of this form, see AEHA TG 155, or DLS SOP NO. 5 DATE SAMPLED FIELD IDENTIFICATION NUMBER LAB NUMBER SAMPLE TYPE C O M P G R A B T O T A L
TOTAL DATE SHIPPED: ____________________ LAB NUMBER CARRIER USED: ____________________________________ DATE/TIME SEAL INTACT: YES
NO
COMMENTS
RELINQUISHED BY
RECEIVED BY
DATE/TIME
REMARKS
Page 1 of 2 CHPPM Form 235-R-E
Replace AEHA Form 235-R, 1 JUN 94, which is obsolete.
CHAIN-OF-CUSTODY RECORD The Proponent of This Form is the Directorate of Laboratory Sciences LAB NUMBER RELINQUISHED BY DATE/TIME RECEIVED BY DATE/TIME COMMENTS
REMARKS
SAMPLE DISPOSAL RECORD LAB NUMBER DATE OF DISPOSAL NUMBER OF CONTAINERS SIGNATURE REMARKS
Page 2 of 2 CHPPM Form 235-R-E
Replace AEHA Form 235-R, 1 JUN 94, which is obsolete.