Chain of Custody Form Laboratory - Excel

							                                                                                                         Columbia Analytical Services
                                                                                                         3860 S. Palo Verde Rd, Suite 302
                                                                                                         Tucson, AZ 85714
   www.caslab.com/Tucson-Laboratory                                                                      520.573.1061 - 520.573.1063 (fax)
                                                                                                         email:      tucsonlab@caslab.com
                                                             Chain of Custody Form
                   (2 samples per form, use additional forms as needed, enter all client information on 1st form)
                                 Results To                                                                             Invoice To
       Client :                                                                               Client :
   Address:                                                                                Address:




  Attention:                                                                              Attention:
 Phone/Fax:                                                                              Phone/Fax:
       Email:                                                                                 Email:
Project / PO:

  Signature:                                                                         Submittal Date:


            Sample ID:                                                                             Sample ID:
Analyses Requested:                                                                    Analyses Requested:



                   single             dup                    dup out of range                            single               dup                   dup out of range

  Type of Compound:                                                                       Type of Compound:
    Elements Present:                                                                      Elements Present:
                    (provide structure on back if known)                                                 (provide structure on back if known)
                   Theory or Range of Concentration                                                      Theory or Range of Concentration
  C=                        %                                              %             C=                        %                                              %
  H=                        %                                              %             H=                        %                                              %
  N=                        %                                              %             N=                        %                                              %
  O=                        %                                              %             O=                        %                                              %
  S=                        %                                              %             S=                        %                                              %
  Melting Pt.:              °C                Boiling Pt.:                 °C            Melting Pt.:              °C                Boiling Pt.:                 °C
                  Special Sample Handling and Fees                                                    Special Sample Handling and Fees
        Air sensitive, transfer under N ($15.00/transfer)                                     Air sensitive, transfer under N ($15.00/transfer)
        Dry prior to analysis ($10.00)                                          ºC            Dry prior to analysis ($10.00)                                           ºC
        Dry prior to analysis & LOD ($20.00)                                    ºC            Dry prior to analysis & LOD ($20.00)                                     ºC
        Dry under vacuum ($20.00)                                               ºC            Dry under vacuum ($20.00)                                                ºC
        Dry under vacuum & LOD ($30.00)                                         ºC            Dry under vacuum & LOD ($30.00)                                          ºC
        Prep/grinding ($10.00 to $30.00)                                                      Prep/grinding ($10.00 to $30.00)
     (if not marked, client will be notified if samples require prep)                        (if not marked, client will be notified if samples require prep)

        Hazardous Sample Return ($10.00 / batch)                                              Hazardous Sample Return ($10.00 / batch)
        Sample Return ($10.00 / per batch of samples)                                         Sample Return ($10.00 / per batch of samples)
                        Rush Service and Fees                                                                 Rush Service and Fees
        Same Day (200%)                          2-3 Bus. Days (50%)                          Same Day (200%)                            2-3 Bus. Days (50%)
        Next Day (100%)                          4-6 Bus. Days (20%)                          Next Day (100%)                            4-6 Bus. Days (20%)

                                                                      Sample Received By:

  Signature:                                                                         Received Date:



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