Laserfiche WebLink
AMC MI"' Chain of Custody and Analytical Request Record Page of <br /> PLEASE PRINT-Provide as much information as possible. <br /> Company Name: Project Name, PWS, Permit, Etc. Sample Origin EPA/State ompliance: <br /> State: U'--- Yes No ❑ <br /> eport Mail A d ts: Contact Name: Ph e/Fax: Email: Sampler: (Please Print) <br /> Invoice Address- Invoice Contact& Phone: Purchase Order: Quote/Bottle Orde1w. <br /> Special Report/Formats—ELI must be notified Contact ELI prior to Shipped by: <br /> prior to sample submittal for the following: o RI RUSH sample submittal c aer IO(s): <br /> E m W s for charges and <br /> scheduling—See <br /> (53 N W Instruction Page /1 9 <br /> N = d <br /> ❑ DW El A2LA U¢vl o U 3 Comments: Reca' Temp o <br /> ❑ GSA El EDD/EDT(Electronic Data) Ca,ml - C <br /> to o c On Ice- <br /> ❑ POTW/WWTP Format: �,�I O Q <br /> El State: El LEVEL IV E E<c eal Y <br /> es No <br /> ❑ N E LAC z M I>I W Ta Custody S <br /> ❑ Other: � E H Bottles/ <br /> Z <br /> Coolers B C <br /> Intact N <br /> SAMPLE IDENTIFICATION Collection Collection MATRIX .� ,� signature Y N <br /> Name, Location,Interval,etc. Date Time Match <br /> soo <br /> 4 <br /> 6 <br /> Q <br /> 7 <br /> q <br /> B t] <br /> 9 p0 <br /> q <br /> tl] <br /> Cu.S•`ody Reli�ished py(print): Date/Time: ature: Received by(print): Datefrime: Signature: <br /> Record elinquished by(print): Datelrme: Received by(print): Daternme: Signature: <br /> MUST be <br /> SRMIby laboratory: Date/Time: Signature: <br /> Signed Sample Disposal: Return to Client: Lab Disposal: <br /> In certain circumstances,samples submitted to Energy Laboratories, Inc.may be subcontracted to other certified laboratories in order to complete the analysis requested. <br /> This serves as notice of this possibility. All sub-contract data will be clearly notated on your analytical report. <br /> Visit our web site at www.energvlab.com for additional information,downloadable fee schedule,forms, and links. <br />