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Country:
Email(s) for Report:
Sampled By Name: Sampled By Signature:
Date/Time:
Date/Time:
Controlled Document - COC-31 Crypto/Giardia R9 3/18/21
Please use COC-75 Aquatic Microbiology for Microscopic Particulate Analysis (MPA).
Client
Sample
ID
Test CodeDate/Time
SampledSample Type Volume Filtered
(Liters)*Filter Clog?*
Number of
Filters*
Field Filtered Samples
Temp Acceptable
During Transport?
(0-20°C for crypto)
Lab Use Only
PWS ID: Facility ID: Collection Point ID: Source ID:
• M640 Cryptosporidium and Giardia (EPA 1623.1)• M114 E. coli (MPN by SM 9223B)
• M641 Matrix Spike for Cryptosporidium and Giardia (EPA 1623.1)
Relinquished by: Received by:
Special Instructions and/or Regulatory Requirements (Sample Specifications, Processing Methods, Limits of Detection, etc.)
Packing (place the temperature strips or logger into the coolers) Name: Date/Time
No. of Samples in Shipment
TAT (Turnaround time): 1 Week 2 Week Other (Specify):
Please fill one sample per row.• Please collect 10 liters water for each LT2 cryptosporidium compliance sample.
• Cryptosporidum samples will be rejected if hold time > 48 hours, if sample temperature exceeds 20°C or is frozen, or if samples leak. • E. coli samples must be shipped as soon as possible as the hold time is 30 hours, and the acceptable temperature is 0- 10°C upon receipt.• For swimming pool water (non-LT2), please submit 1 liter backwash water.
• Please contact lab about sampling for any other water bodies.
Temp. upon
Receipt (°C)
LT2 Chain of Custody FormEMSL Order Number / Lab Use Only
If Bill-To is the same as Report-To leave this section blank. Third-party billing requires written authorization.Customer ID: Billing ID:
Company Name:
Street Address: Street Address:
Billing Contact:
Purchase Order:
City, State, Zip: City, State, Zip: Country:
Phone: Phone:
Project Name/No:
US State where samples collected:
State of Connecticut (CT) must select project location:
Project Information
Cu
sto
mer
Info
rmati
on
Email(s) for Invoice:
Billin
g In
form
ati
on
EMSL LIMS Project ID: (If applicable, EMSL will provide)
Test Codes
Company Name:
Contact Name:
Date/Time
EMSL Analytical, Inc.’s Laboratory Terms and Conditions are incorporated into this Chain of Custody by reference in their entirety.
Submission of samples to EMSL Analytical, Inc. constitutes acceptance and acknowledgment of all terms and conditions by Customer.
Method of Shipment: Sample Condition Upon Receipt:
Relinquished by: Received by: Date/Time
Page 1 of
PHONE:EMAIL:
Commercial (Taxable) Residential (Non-Taxable)
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
AGREE TO ELECTRONIC SIGNATURE (By checking, I consent to signing this Chain of Custody document by electronic signature.)
Date/Time:
Date/Time:
Controlled Document - COC-31 Crypto/Giardia R9 3/18/21
Lab Use Only
Volume Filtered
(Liters)*Filter Clog?*
Number of
Filters*
Temp Acceptable
During Transport?
(0-20°C for crypto)
Temp.
upon Receipt
(oC))
LT2 Chain of Custody Form
Client
Sample
ID
Received by: Date/Time
Method of Shipment: Sample Condition Upon Receipt:
EMSL Analytical, Inc.’s Laboratory Terms and Conditions are incorporated into this Chain of Custody by reference in their entirety. Submission of samples to EMSL
Analytical, Inc. constitutes acceptance and acknowledgment of all terms and conditions by Customer.
Relinquished by: Received by: Date/Time
Relinquished by:
Additional Pages of the Chain of Custody are only necessary if needed for additional sample informationSpecial Instructions and/or Regulatory Requirements (Sample Specifications, Processing Methods, Limits of Detection, etc.)
EMSL Order Number / Lab Use Only
Test CodeDate/Time
SampledSample Type
Field Filtered Samples
Page of
Yes / NoRegular Matrix Spike Yes No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Yes No
Yes No
Yes No
Yes No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
Regular Matrix Spike
PHONE:EMAIL:
AGREE TO ELECTRONIC SIGNATURE (By checking, I consent to signing this Chain of Custody document by electronic signature.)
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