1414 Stanislaus St., Fresno, CA 93706
(559) 497-2888 ∙ Fax (559) 497-2893
Fresno
Sacramento
3140 Gold Camp Drive Suite 160, Rancho Cordova, CA 95670
(916) 853-9293 · Fax (916) 853-9297
*Required Fields
Company/Client Name*:
MICROBIOLOGY
CHAIN OF CUSTODY
www.bskassociates.com
Temp
Report Attention*:
Invoice To*:
Additional cc's:
PO#:
Phone*:
Fax*:
E-mail*:
Zip*:
Reporting Options
EDD Type: ___________________
Fresno Co.
Sac Co.
Date
Time
PA
1X10
3X5
Fecal
Solids
HPC
Date Needed ______________
Field Notes
Cl2 Res
Source
Turbidity
Type
Other
Sample Description*
#
Colilert
Sampled*
Rush (Surcharge)
Mail
(1 X 10)
72 Hour
48 Hour
FAX
Class B
Fecal
Class A
Init.
E-Coli
2nd Phone:
E-Mail
Total
1st Phone:
Date:
Time:
E-Coli
Contact:
Fecal
Name:
Total
Lab Use Only
Standard - 10 Business Days
TAT*
How would you like your completed results sent?
All drinking water bacteria samples will have verbal results available the morning of the second day. A written report will be provided in 7-10 business days. Other reporting arrangements
can be made for an additional fee. All samples submitted for compliance with the total coliform rule must include a phone number to a live person, no answering machines or services.
IF SAMPLE IS COLIFORM POSITIVE CONTACT*
No
Replacement
Yes
Regulatory Sample*:
Repeat
Sampler Name (Printed / Signature)*:
Tulare Co.
Other: _________________________________
Routine
Merced Co.
WaterTrax ID#:_________________
SWRCB
LT2ESWTR
Copies to:
Solid
Project #:
Surface Wtr
SWAMP
Project:
WW
State*:
DW
City*:
Quantitray
Address*:
Notes / Comments
Relinquished by: (Signature and Printed Name)
Company
Date
Time
Received by: (Signature and Printed Name)
Company
Relinquished by: (Signature and Printed Name)
Company
Date
Time
Received by: (Signature and Printed Name)
Company
Date
Time
Container(s) Received:
Received for Lab by: (Signature and Printed Name)
BSK Bottle = 120mL Plastic Serial w/ NA2S2O3
Other =
Shipping Method:
Packing Material:
Cooling Method:
ONTRAC
Bubble Wrap
Wet
Blue
UPS
GSO
Paper
Other
None
WALK-IN
FED EX
Condition of Sample:
Chilling Process Begun: Y / N
Courier: ___________
Acceptable
Payment Received at Delivery:
Check
/
Cash
/
Card
Other
Custody Seal: Y / N
Date:
PIA#:
Init.
Payment for services rendered as noted herein are due in full within 30 days from the date invoiced. If not so paid, account balances are deemed delinquent. Delinquent balances are subject to monthly service charges and interest specified in BSK’s current Standard Terms and Conditions for Laboratory Services. The person signing for the
Client/Company acknowledges that they are either the Client or an authorized agent to the Client, that the Client agrees to be responsible for payment for the services on this Chain of Custody, and agrees to BSK’s terms and conditions for laboratory services unless contractually bound otherwise. BSK’s current terms and conditions can be
found at www.bskassociates.com/BSKLabTermsConditions.pdf
SR-FL-0006-06 Microbiology Chain of Custody