Chain of Custody Record Microbac Laboratories Inc - Excel by pwz60985

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									                                                         Chain of Custody Record
                                                                      Microbac Laboratories, Inc.                                       Certificate of Analysis No.
                                                                      Kentucky Testing Laboratory Division
                                                                      3323 Gilmore Industrial Blvd., Louisville, KY 40213
                                                                      (502) 962-6400 fax (502) 962-6411

Report To:                                   Microbac Information:
Name:
Address:                                     Template Name:
                                             Additional Labor:__________
Phone:                                Fax:
PO#:
 Permit #          WWTP        Frequency     Project or Subject Reference                                                   Samplers (signature):

                                                   Collected                                                                 Grab/     No. of   Cont.
Sample ID Sample Description                    Date       Time                        Analysis Requested                    Comp.     Cont.    Type    Preservative




Relinquished By:                                         Date/Time:                       Field Parameters:
                                                                                          pH: _________ Temperature: ___________ Flow: ______________ GPD
Received By:                                             Date/Time:
                                                                                          Field Limits:                     Type of Flow:
Relinquished By:                                         Date/Time:                       pH:
                                                                                          Temperature:
Received at Lab By:                                      Date/Time:

                                                            f14a3cdf-5827-4ecf-9114-cfda636402c6.xls                                                     Page 1

								
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