CHAIN OF CUSTODY
Results To: Bill To:
Company     Company  
311 North Aspen Name             Name  
Broken Arrow, OK 74012 Address             Address  
Phone: (918) 251-2515 City   State   Zip   City   State   Zip  
Fax: (918) 251-0008 Phone   Fax      
www.outreachlab.com                                      
ANALYSIS REQUESTED
PO #       # Containers Container Size Plastic or Glass Preservative # 1. HNO3 pH<2 2. Ice <4°C 3. HCI pH<2 4. H2SO4 pH<2 5. NaOH pH>11                 Remarks (I.E. Filtered, Unfiltered, Grab, Composite)
Project #      
Project Name      
Requested Turnaround Time      
(Additional Charges May Apply)
Sampler Signature      
Lab Sample ID Client Sample ID Date Sampled Time Sampled Matrix
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                 
                                            Method of Transport:
RELINQUISHED BY   DATE ____________ TIME __________ RECEIVED BY: _______________________ DATE ____________ TIME ________            
             
     
RELINQUISHED BY   DATE ____________ TIME __________ RECEIVED BY: _______________________ DATE ____________ TIME ________   Sample Condition Upon Receipt:
             
My signature on this chain of custody form indicates that I am authorized by the above company to release samples for analysis.          
         
         
The company agrees to pay the entire balance upon receipt of sample data and it is understood and agreed that any balance carried over thirty (30) days is subject to a 1.5% per month (18% per annum) late charge. In the event of default, the company becomes legally liable for any reasonable attorney and/or collection fees and all related costs necessary to remit the entire balance to Custody Seals Intact: Y N
Outreach Technologies, Inc. (Outreach Laboratory). Cooler Temperature:____________
SAMPLE RETURN/DISPOSAL: All non-hazardous samples shall be disposed of 30 days after issue of final report. All others will be returned at client's expense.