Water Testing Chain of Custody Form
Use this form to document sample handoff and tracking for water testing. All entries are required for operational accuracy.
Sample ID
*
Collection Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Sample Location/Source
*
Sample Type
*
Please Select
Drinking Water
Surface Water
Groundwater
Wastewater
Stormwater
Other
Collector Name
*
First Name
Last Name
Collection Organization/Company
*
Sample Condition at Collection
*
Please Select
Intact
Leaking
Broken Seal
Temperature Concern
Other
Requested Analyses/Testing Parameters
*
Chain-of-Custody Transfer Log (list each handoff: date/time, from whom, to whom, signatures if applicable)
*
Receiving Laboratory/Contact Details
*
Submit
Should be Empty: