Chain of Custody Form
Report To Information
Bill To Information (If different from report to)
Company Name:
Company Name:
Contact Name:
Contact Name:
Address:
Address:
State
Phone:
Task Number (Lab Use Only)
Zip
City
State
Fax:
Phone:
Fax:
Phone: 303-659-2313
Fax: 303-659-2315
Zip
www.coloradolab.com
Disposal Date(Lab Use Only)
Email:
Email:
Sample Collector:
PO No.:
Waste Water
Soil
Plant Tissue
Ground Water
Sludge
Other
Surface Water
Compost
Time
No. of Containers
Sample Matrix (Select One Only)
Date
Sample ID
C/S Info:
Instructions:
Seals Present Yes
Deliver Via:
Relinquished By:
Date/Time:
Received By:
Brighton Lab
240 South Main Street
Brighton, CO 80601
Lakewood Lab
12860 W. Cedar Dr, Suite 100A
Lakewood CO 80228
Grab
or (Check One Only)
Composite
City
Project Name
Date/Time:
Relinquished By:
C/S Charge
Date/Time:
Temp.
°C/Ice
Received By:
No
Sample Pres. Yes
No
Date/Time: