Industrial Hygiene Associates
|
359 DRESHER ROAD HORSHAM, PA 19044 (215)672-6088 (215)443-0899 FAX kcrawford@eagleih.com |
Sample Transmittal Record / Chain of Custody Record
Click here to download the Sample Transmittal Record / Chain of Custody Record form, which can then be printed, filled out, and returned to Eagle. Once you are viewing the form in your browser and wish to return to Eagle's site, click the Back button.
1. CLIENT PLEASE FILL IN YOUR COMPANY NAME, ADDRESS, ZIP CODE
2. POINT OF CONTACT - NAME OF PERSON TO CONTACT WITH RESULTS AND/OR QUESTIONS
3. PHONE NUMBER PHONE NUMBER AND FAX NUMBER OF CONTACT
4. PROJECT ID LOCATION OF SAMPLING, IF DIFFERENT THAN CLIENTS ADDRESS
5. REPORT NUMBER -N/A-GIVEN BY EAGLE INDUSTRIAL HYGIENE
6. LAB NUMBER - N/A-GIVEN BY EAGLE INDUSTRIAL HYGIENE
7. FIELD SAMPLE NUMBER INITIAL OF PERSON TAKING SAMPLE, MONTH, DATE, AND BEGINNING SAMPLE NUMBER (IE, MH030501, MHO30502, ETC.)
8. ANALYSIS REQUESTED PUT E&S FOR BOTH AIR SAMPLES, TAPE, BULK AND SWAB SAMPLES
9. DESCRIPTION PUT A THOROUGH DESCRIPT ION OF WHERE SAMPLE WAS TAKEN
10. RESULTS UNDER RESULTS PUT HOW MANY MINUTES SAMPLING WAS DONE AND AIR FLOW (IE, 3 MINS @ 24 LPM (AIR FLOW FOR SAMPLER). FOR SWAB SAMPLES PUT AREA TESTED (IE, 2in2 )
11. COLLECTED BY PERSON TAKING SAMPLES
12. RECEIVED BY/CHAIN OF CUSTODY INITIATED BY PERSON FILLING OUT CHAIN OF CUSTODY
13. DATE&TIME DATE AND TIME SAMPLES ARE TAKEN
14. RELINQUISHED BY/DATE NAME OF PERSON RELINQUISHING SAMPLES AND DATE (TME/RECEIVED BY NA)
15. SUBMITTED TO LAB BY/DATE METHOD OF SENDING SAMPLES (IE, US MAIL, FEDEX, UPS, ETC., INITIALS OF PERSON SUBMITTING SAMPLES AND DATE
REST OF CHAIN-OF-CUSTODY TO BE FILLED OUT BY EAGLE INDUSTRIAL HYGIENE
DO NOT SEND PLATES BACK FOR TESTING ON A FRIDAY! THE BEST WAY TO SHIP IS PRIORITY OVERNIGHT SO PLATES AND COLD PACK WILL STILL BE COOL, OTHERWISE THEY WILL HAVE GROWTH WHEN RECEIVED BY EAGLE INDUSTRIAL HYGIENE, AND SAMPLES WILL BE VOIDED.
TSA FOR BACTERIA MEA FOR FUNGI (WRITTEN ON EACH PLATE)