DU204SA-15-R-0002_Attachment_4.pdf

Attachment 4 to Section J

CHAIN OF CUSTODY FORM Page of Laboratory Identification and Address:

CLEARANCE EXAMINER INFORMATION

PROCESSING Check/complete all that apply

Clearance Examiners Firm Normal (2-day) Rush ( hours)

E-mail Firm Contact Name Fax

Firm Address Special requirements:

CLEARANCE EXAMINER'S PROJECT

NAME/NUMBER

City, State Zip CLEARANCE EXAMINER'S NAME/DATE Phone Fax Email (if it is to be used)

Purchase Order No. Client Name/No. Due Date: ___________________

SAMPLING SITE (Street Address/Unit):

DATE Time Sample

ID

Sampling Location Sample Dimensions

(in. x in.) SAMPLE

MATRIX

META

L

Analytic al Units

FOR LAB

USE ONLY COMMENTS

X PAINT SOIL WIPE LEAD

3 X PAINT SOIL WIPE LEAD

5 X PAINT SOIL WIPE LEAD

6 X PAINT SOIL WFE LEAD

7 X PAINT SOIL WHE LEAD

8 X PAINT SOIL WIPE LEAD

9 X PAINT SOIL WIPE LEAD

10 X PAINT SOIL WIPE LEAD

SAMPLE TRACEABILITY FOR LABORATORY USE ONLY

Date Received Signature Organization Date Relinquished

1 Date received at lab: Tine received at lab:

2 Means of delivery to lab:

3 Date checked in: Entry clerk name:

4 Analyst name: Date analysis run:

5 Worksheet No.

6 Results reviewed by: Review date:

7 Date sent: Means of delivery: