Chain_of_Custody.pdf
PDF 170 KB Posted
- Attached to
- Laboratory Testing Services
- Solicitation number
- 262830RM
- Issued by
- Sarasota County, Siesta Key CDP, Florida
About this file
This is a Chain of Custody Form Example prepared for Sarasota County Utilities Department in Florida, serving as Attachment B to laboratory testing services documentation. The form establishes procedures for tracking water and wastewater samples from collection through laboratory analysis, including sample identification, preservation methods, and chain of custody documentation across multiple transfer points. The example specifies sample matrix types (wastewater designated as "WW"), various analysis parameters including TDS, chloride, sulfate, BOD, CBOD, NOX, NO2, NO3, NH3, TKN, TP, CN, and metals (Al, As, Ca, Cd, Cr, Cu, Fe, Pb, Mg, Mn, Mo, Ni, K, Se, Na, Zn), with corresponding preservatives such as plain containers, sulfuric acid solutions, ascorbic acid, and nitric acid depending on analyte requirements. Laboratory contact information is provided as 1301 Cattlemen Road, Sarasota, FL 34232, with telephone and fax numbers.
The form includes comprehensive instructions for sample collection, labeling, and custody documentation, requiring permanent black ink notation of collection date and time, sampler identification, and field numbers on bottle labels. All bottles must be properly labeled with sample ID, client ID, and pre-measured preservatives prior to collection, with non-preserved bottles permitted to be rinsed with sample water beforehand. Temperature control requirements mandate refrigeration or wet ice storage maintaining maximum temperatures of 6°C (42.8°F) following collection. The chain of custody section documents three sequential transfer points, each requiring relinquishing and receiving party signatures with corresponding dates and times, ensuring sample integrity tracking. Laboratory sample acceptability determination, including pH verification, concludes the standardized process, with the client responsible for documenting all sampling events and noting any special sampling circumstances on the form.
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Text version
ATTACHMENT B CHAIN OF CUSTODY FORM
EXAMPLE LABORATORY
1301 Cattlemen Rd Sarasota, Fl, 34232
(941) 555-8888
(941) 555-8888 fax www.examplelaboratory.com
Client: Sarasota County Utilities Department 1255 T. Mabry Carlton Parkway Venice, FL 34292
(941) 650-XXXX
(941) 480-XXXX fax
Project Name:
Purchase Order Number:
Laboratory Submission #:
Station
ID:
Sample Matrix2
Sample Type1
Analysis Requested:
Laboratory Sample #
TDS, Chloride, sulfate
BOD,
CBOD
NOX
NO2,
NO3
NH3 TKN
TP
CN Al, As, Ca, Cd, Cr, Cu, Fe, Pb, Mg, Mn, Mo, Ni, K, Se, Na, Zn
Preservative:
Plain
Plain Plain 1:4
H2SO4
1:4
H2SO4
Ascorbic Acid
1:4 HNO3
Example WW Grab Date & Time:
Date & Time:
Date & Time:
Date & Time:
Date & Time:
1 “Sample Type” is used to indicate whether the sample was a grab (G) or whether it was a composite (C).
2 “Sample Matrix” is used to indicate whether the sample is being discharged to drinking water (DW), groundwater (GW), surface water (SW), soil, sediment (SDMNT), or sludge (SLDG).
3 “Container Type” is used to indicate whether the container is plastic (P) or glass (G).
4 Sample must be refrigerated or stored in wet ice after collection. The maximum temperature during storage should be 6°C (42.8°F).
Under “Preservative,” list any preservatives that were added to the sample container.
Instructions:
1. Each bottle has a label identifying sample ID, premeasured preservative contained in the bottle, sample type, client ID, and parameters for analysis.
2. The following information should be added to each bottle label after collection with permanent black ink: date and time of collection, sampler’s name or initials, and any field number or ID.
3. All bottles not containing preservative may be rinsed with appropriate sample prior to collection.
4. The client is responsible for documentation of the sampling event. Please note special sampling events on the sample custody form.
1 Collector – Relinquished by: Date: Time: Received By: Date: Time:
2 Relinquished by: Date: Time: Received By: Date: Time:
3 Relinquished by: Date: Time Received By: Date: Time
Laboratory Sample Acceptability: pH <2 : �
LAB Temperature:
LAB Temperature:
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