Company Name

Project Name

Date of Collection

YYYY

Contact Name

First Name

Last Name

Contact Email

Work Order/Project ID

Contact Phone Number

(###)

###

####

Additional Analysis / Comments

Chain of Custody:

You can also fax an updated copy of your Chain of Custody to (206)352-7178. Or, you can email an updated Chain of Custody to us.

Notes:

Please make sure to include the Sample ID for each additional analysis requested.

If you fax or email your updated Chain of Custody, please specify the additional analysis for each sample. You must also initial and date each request in the comments field.