Geology Sample Discharge Log
Complete this form to record the details of geology samples being discharged from storage or laboratory.
Sample ID or Reference Number
*
Sample Type
*
Please Select
Rock
Soil
Mineral
Sediment
Other
Description of Sample
Quantity Discharged
*
Unit of Measurement
*
Please Select
kg
g
pieces
liters
Other
Date and Time of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Discharged By (Name)
*
First Name
Last Name
Recipient (Name or Organization)
*
Method of Discharge
*
Transfer to Another Facility
Disposal
Return to Owner
Other
Location of Discharge
*
Condition of Sample at Discharge
Please Select
Intact
Damaged
Contaminated
Other
Reason for Discharge
*
Additional Notes
Signature of Responsible Person
*
Submit Log
Submit Log
Should be Empty: