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Example Chain of Custody Form <br />• <br />• <br /> <br />ACZ Laboratories, Inc. m <br />2773 Downhill Drive Steamboat Springs, CO 80487 (800) 334-5493 <br /> <br />Name: Address: <br />Company: <br />E-mail: Telephone: <br />'Copy Report <br />Name: E-mail: <br />Company: Telephone: <br />Invoice to: <br />Name: Address: <br />Company: <br />E-mail: Telephone: <br />If sample(s) received past holding time (HT), or if insufficient HT remains to complete YES <br />analysis before expiration, shall ACZ proceed with requested short HT analyses? NO <br />If "NO" then ACZ will contact client for further instruction. If neither "YES" nor "NO" <br />is indicated, ACZ will proceed with the requested analyses, even if HT is expired, and data will be qualified. <br />PROJECT INFORMATION ANALYSES REQUESTED (attach list or use quote number) <br />Quote #: <br /> <br />Project/PO #: <br />Reporting state for compliance testin : c <br />Samplers Name: U <br />w <br />Are an samples NRC licensable material? <br />SAMPLE • DATE:TIME Matrix <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Matra SW (Surface Water) GW (Ground Water) WW (Waste Water) DW (Drinking Water) - SL (Sludge) -SO (Soil) OL (Oil) -Other (Specify) <br />REMARKS <br />Please refer to ACZ's terms & conditions located on the reverse side of this COC. <br />RELINQUISHED <br /> <br /> <br />FRMAD050.03.05.02 White - Return with sample. Yellow - Retain for your records.