Red Hawk-LR160913C
.FORTWORTH Centralized Water and Wastewater Laboratory
a
2600 S.E. Loop 820 Fort Worth, TX 76140 Phone (817) 392-5900 Fax (817) 392-5920
Please print legibly
CHAIN OF CUSTODY RECORD
State
Project Name
Sampler (Printed)
Client Contact Information
(of sample origin)
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III Illllllfll VIII IIIIIII III Ilt
Tioga Contractors
Attn: Jerry Carter
Prepay
136 S.Norwood Dr., Hurst, TX
76053
TX
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Work Order ID: Tioga JS 091316
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682-224-0757
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amanda@tiogacontractors.com
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CL
E
Sample ID # Collect n ate Collection Time
Sampling Site
Test Name Sample Remarks
4h
Ca
rn
922313 Coli
l�
1
DW
G
,',*DAM
D&rJ7]
9223B -Coli
og S
1
DW
G
AM PM
92236 -Coli
1
DW
G
AM PM
922313 -Coli
1
DW
G
AM PM
1
DW
G
AM PM
1
1 DWI
G
AM PM
1
DW
G
AM PM
1
DW
G
AM PM
1
DW
G
AM PM
AM PM
Field Comments: Carrier
Airbill No
Cooler No. Date Shipped
: (Sign
Date
Time
By: (Sign ur)
to
Time
B COMMENTS Project Information Update: 02/17/16
Vuished
Z.,/ 3
AM
M
lived
AM
PM
IR Thermometer.
: (Signature)
Date
Time
Receiv y: (Signature)
Date
Time
AM
PM
AM
PM
Relinquished By: (Signature)
Date
Time
Received By: (Signature)
Date
Time
CONDITIONS UPON RECEIPT (Check One)
AM
PM
AM
I P.
Ice Ambient a.19 °C Upon Receipt
,
Matrix Codes:
Sample Types
Container Types
DW=Drinking Water
C=Composite
V=VOA Vials
NP=Non-Potable Water
G=Grab
AG=Amber Glass
S=Solid Waste
W W=Wastewater
CG=Clear Glass
P=Plastic
LAB RESERVES THE RIGHT TO RETURN UNUSED PORTIONS OF
NON -AQUEOUS SAMPLES TO CLIENT
OMS -003
Rev. 2 Issue Date: 12/23/2014 Effective Date: 01/01/2015