Sample Chain-of-Custody (Sample Delivery)

Page: __of __

Sampling Code: __________________ Record No.: ____________________

Project: _____________________________ Sampling Date: ____________________

Type of Sample: ______________________ Total No. of Sample: ________________

Sample Storage Condition: _____________________________________________________

Sample Transported from: _______________ to _________________ by: _______________

Sample Code

Sample Vol. (L)

Container Material

Sample Container Condition

Remarks

Checked by

Delivery Date: _________________ Receiving Date: ____________________

Delivery Time: _________________ Receiving Time: ____________________

From: _________________ To: ____________________

Relinquished By: _________________ Receiving By: ____________________