25e_NCS000250_NCDOT_Appendix B_COC for Metals Sampling (Example)_DRAFT

CHAIN -OF -CUSTODY / Analytical Request Document
The Chain -of -Custody is a LEGAL DOCUMENT. All relevant fields must be completed accurately.
Section A Section B Section C
Required Client Information: Required Project Information: Invoice Information: Pa e : 1 Of
Company: Tetra Tech Inc. Report To: ionathan.smith(a tetratech.com Attention:
Address: P.O Box 14409/1 Park Drive, Suite 200 Copy To: maureen.harris(a).tetratech.com Company Name:
Research Triangle Park, NC 27709
Jesse. ohillips(c)tetratech.com
Address:
Regulatory Agency
Email To: j onathan.smith(abtetratech.com
Purchase Order#:
Pace Quote:
NIA
Phone: [phone] Fax, [phone]
Project Name: NCDOT Task Order 07
Pace Project Manager: Nicole Gasiorowski
State I Location
Requested Due Date:
Project Number: 100-RTP-T36943.07
Pace Profile #:
North Carolina
Requested
Analysis
Filtered
(YIN)
a
Z
MATRIX CODE
°
COLLECTED
Preservatives
N
N
N
N
Y
Y
Y
Drinking Water DW
d
c0i
U
Z
O
Water WT
o
~
U
Waste Water WW
_
Q
Z
Product P
SAMPLE ID Soil/SolidoL
K
START
END
s
a
a
Q
One Character per box. Wipe WP
w
w
a
z
Cn
>
°�'
>
8
(A-Z, 0-9 I, -) Air AR
p
}
W
F
d
M
N
U
Other OT
Sample Ids must be unique rssoe rs
U
x
~
w
~
W
Z
o
0
v
O
=,
_
m
_
_
m
O
LLI
g
g
a
M
O
=
O
N
s
c
Q
o
m
0
0
y
y
:o
y
:o
y
~
can
DATE
TIME
DATE
TIME
can
_
_
=
z
z
O
F
a
i
a
U
i i
a
1
EXAMPLE: LW-BS3-Inlet
WT
G
12-Jun
2:45 PM
n/a
n/a
X
2
EXAMPLE: LW-BS3-Inlet-TOT
WT
G
12-Jun
2:45 PM
n/a
n/a
X
X
X
X
3
EXAMPLE: LW-BS3-Inlet-IMM
WT
G
12-Jun
2:45 PM
n/a
n/a
X
X
X
X
4
EXAMPLE: LW-BS3-Inlet-DEL
WT
G
12-Jun
2:45 PM
n/a
n/a
X
X
X
X
5
EXAMPLE: LW-BS3-Under
WT
G
12-Jun
2:56 PM
n/a
n/a
X
6
EXAMPLE: LW-BS3-Under-TOT
WT
G
12-Jun
2:56 PM
n/a
n/a
X
X
X
X
7
EXAMPLE: LW-BS3-Under-IMM
WT
G
12-Jun
2:56 PM
n/a
n/a
X
X
X
X
8
EXAMPLE: LW-BS3-Under-DEL
WT
G
12-Jun
2:56 PM
n/a
n/a
X
X
X
X
9
10
11
12
ADDITIONAL COMMENTS
RELINQUISHED BY I AFFILIATION
DATE
TIME
ACCEPTED BY / AFFILIATION
DATE
TIME
SAMPLE CONDITIONS
SAMPLER NAME AND SIGNATURE
c
U
O
PRINT Name of SAMPLER:
w
z
o z
E z
SIGNATURE of SAMPLER:
DATE Signed:
F
K cOi}
�U}
to c}