Lab Sample Chain-of-Custody Form
A sample tracking form that documents each sample from collection through analysis. Required for permit-submittal data and any sample that may be used for enforcement or litigation.
LAB SAMPLE CHAIN OF CUSTODY
Complete one form per sampling event · Sign each transfer
Date
8/26/2026
1. Sampling Event Information
Plant / facility
Collected by
Date / time collected
Sampling methodGrab / composite
2. Sample Inventory
No.Location / IDSample typeAnalysesPreservationContainersTime
1
2
3
4
5
6
Sample type: Influent · Effluent · MLSS · RAS/WAS · Sludge · Other ｜ Preservation: Cool 4°C · H₂SO₄ · HNO₃ · NaOH · AsReceived · Other
3. Custody Transfer
Relinquished byDate / timeReceived byDate / timeNotes
4. Condition on Receipt
Temperature on receipt°C
Intact? (Y/N)
Received by
Date / time received
5. Sampler / Lab Sign-off
Sampler signature
Date / time
Lab receiving signature
Date / time
Samples are in custody when in physical possession, in view, or secured in a restricted area. A broken chain invalidates use of the result for enforcement or litigation.