Please fill out the client information, including:

  • Client Name (*required): Company or client name
  • Email (*required): contact e-mail
  • Address (*required): Company or client address
  • Project Name (optional)
  • Project Number (optional)
  • P.O. Number (optional)
  • Project Manager (optional)
  • Phone Number (*required)
  • Fax Number (required if results are to be faxed)
  • Sampler Name (*required)
  • Sampler Signature (*required)
  • TAT (Analytical Turn Around Time) (*required): (0 = same day, 1 = 24 hours, 2 = 48 hours, etc., N = normal); circle one or type in field
  • Analysis/Analyses Requested (*required): name of analysis/analyses

For each Sample:

(“Sample No.” is for lab use; please leave blank)

  • Date Sampled (*required): mm/dd/yy or mm/dd/yyyy
  • Time Sampled (*required): 00:00 (military time or indicating am/pm)
  • Sample Description (*required): (you may include your own sample IDs here)
  • Matrix (Water or Other) (*required): Other includes soil, food, juice, etc.
  • Container (Qty., type, Grab/Comp) (*required): number, type of containers
  • Analysis (Check box) (*required): check off analysis/analyses requested for each sample

If using multiple pages, you may indicate so on the top right of the page.

Special instructions may be indicated on the bottom of the page.

Please sign under Relinquished by (*required) and Received by (*required) as necessary.

Please contact us if you have any questions.