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Chain of Custody Form
Date Sample Collected

Site ID and Description

Time Sample Collected

Number of Samples

Sample Source:

Sampler Name (printed):

Sampler Signature:

Recreational Waters

Other Waters (please specify)

Place sample on ice immediately. Deliver to the Lab within 6 hours of sampling.

Field Data
Dissolved Oxygen (mg/L)

pH

Salinity (ppt)

Air Temperature (0C)

Tide Stage

Secchi Disk Transparency
(meters)

Weather Conditions

Algae Cover

Total Depth
(meters)

Water Temperature (0C)

Water Color

Sample Depth
(meters)

Water Conditions

Water Odor

Last Significant Precipitation
(runoff)

Water Surface

Water Clarity

Rainfall Accumulation
(last 3 days)

Laboratory Use Only
Analytical Method:

Sample Condition:

Volume Analyzed:

Comments:

Relinquished By: __________________________________

Date / Time: ______________________________

Received By Lab: __________________________________

Date / Time: ______________________________
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Chain of custody form

  • 1. Chain of Custody Form Date Sample Collected Site ID and Description Time Sample Collected Number of Samples Sample Source: Sampler Name (printed): Sampler Signature: Recreational Waters Other Waters (please specify) Place sample on ice immediately. Deliver to the Lab within 6 hours of sampling. Field Data Dissolved Oxygen (mg/L) pH Salinity (ppt) Air Temperature (0C) Tide Stage Secchi Disk Transparency (meters) Weather Conditions Algae Cover Total Depth (meters) Water Temperature (0C) Water Color Sample Depth (meters) Water Conditions Water Odor Last Significant Precipitation (runoff) Water Surface Water Clarity Rainfall Accumulation (last 3 days) Laboratory Use Only Analytical Method: Sample Condition: Volume Analyzed: Comments: Relinquished By: __________________________________ Date / Time: ______________________________ Received By Lab: __________________________________ Date / Time: ______________________________