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 document from a laboratory located in Sarasota, Florida, prepared for Sarasota County Utilities Department in support of the county's laboratory testing services solicitation. The form serves as the standardized template for tracking water, wastewater, and other environmental samples from collection through laboratory analysis. The example illustrates the sample submission process for the Sarasota County Utilities Department, documenting various analytes including TDS, chloride, sulfate, BOD, CBOD, nitrogen oxides, ammonia, total Kjeldahl nitrogen, total phosphorus, cyanide, and metals (aluminum, arsenic, calcium, cadmium, chromium, copper, iron, lead, magnesium, manganese, molybdenum, nickel, potassium, selenium, sodium, and zinc). Samples are designated by type (grab or composite), matrix (drinking water, groundwater, surface water, soil, sediment, or sludge), and appropriate preservatives such as sulfuric acid, nitric acid, or ascorbic acid based on the analysis requested.
The Chain of Custody Form establishes mandatory procedures for sample handling, labeling, and temperature control throughout the testing process. Each bottle must be labeled with sample identification, preservative type, client information, and analysis parameters, with collection date, time, sampler identification, and field numbers added in permanent black ink after collection. Samples must be refrigerated or stored in wet ice at a maximum temperature of 6°C (42.8°F) following collection. The form includes sequential documentation sections for sample relinquishment and receipt, allowing three transfer points to track sample custody from initial collection through laboratory analysis. Instructions specify that bottles without preservatives may be rinsed with appropriate sample prior to collection, and clients are responsible for documenting all sampling events, including notation of any special sampling circumstances on the custody 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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