Chain_of_Custody_Form.pdf
PDF 171 KB Posted
- Attached to
- Laboratory Testing Services Categories I and II
- Solicitation number
- 262894RM
- 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 by a laboratory located in Sarasota, Florida, supporting the county's laboratory testing services contract for water, wastewater, stormwater, and solid waste systems. The form serves as a standardized documentation template for tracking water and wastewater samples throughout the collection and analysis process. The form captures essential sample information including sample matrix type (drinking water, groundwater, surface water, soil, sediment, or sludge), sample type (grab or composite), analysis parameters requested (such as TDS, chloride, sulfate, BOD, CBOD, NOx, ammonia, TKN, TP, cyanide, and metals including aluminum, arsenic, cadmium, chromium, copper, iron, lead, magnesium, manganese, molybdenum, nickel, potassium, selenium, sodium, and zinc), and appropriate preservatives for each analysis type. The form includes designated spaces for recording sample collection dates and times, collector information, and chain of custody handoff documentation through multiple relinquishment and receipt stages.
The form establishes strict sample handling protocols requiring that bottles be labeled with sample ID, sample type, client ID, analysis parameters, and collection details including date, time, sampler identification, and field numbers recorded in permanent black ink. Samples requiring preservation must be refrigerated or stored in wet ice at a maximum temperature of 6 degrees Celsius (42.8 degrees Fahrenheit). The client, identified as Sarasota County Utilities Department, bears responsibility for documenting the sampling event and noting any special sampling circumstances on the custody form. The form includes a laboratory sample acceptability section referencing pH parameters, ensuring analytical quality assurance throughout the testing process.
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Text version
ATTACHMENT C 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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