Country:
Email(s) for Report:
State
Samples
Collected:
Sampled By Name: Sampled By Signature:
M001 Air-O-Cell M174 MoldSnap M012 Pseudomonas aeruginosa (P/A***) M115 Sewage Screen - Water (P/A***)
M030 Micro 5 M032 Allergenco-D M024 Pseudomonas aeruginosa (MFT*) M116 Sewage Screen - Water (MPN**)
M041 Fungal Direct Examination M015 Heterotrophic Plate Count M117 Sewage Screen - Swab (P/A***)
M169 Pollen ID & Enumeration M017 Total Coliform & E. Coli (Colilert P/A***) M013 Sewage Screen - Swab (MFT*)
M280 Dust Characterization Level-1 M018 Total Coliform & E. Coli (MFT*) M730 Methicillin-resistant Staph, aureus (MRSA)
M281 Dust Characterization Level-2 M114 Total Coliform & E. Coli Enumeration (Colilert MPN**)
M005 Viable Fungi-Air Samples (Genus ID & Count) M019 Fecal Coliform (MFT*)
M020 Fecal Streptococcus (MFT*) M014 Endotoxin Analysis
M029 Enterococci (MFT*) M044 Group Allergen (Cat, Dog, Cockroach, Dust Mite)
M129 Enterococci (Enterolert P/A***) M095 Bacteroides
M180 Real Time qPCR-ERMI 36 Panel Other - See Analytical Price Guide for Test Code
M025 Sewage Screen - Water (MFT*)
Legionella Analysis Please use EMSL Legionella COC
*MFT= Membrane Filtration Technique
**MPN = Most Probable Number
***P/A = Presence/Absence
Date/Time:
Date/Time:
Controlled Document - COC-34 Micro R13 03/02/2021
M006 Viable Fungi-Air Samples (Includes Penicillum, Aspergillus,
Cladosporium, Stachybotrys Species ID & Count)
M007 Culturable Fungi-Surface Samples (Genus ID & Count)
M008 Culturable Fungi-Surface Samples (Includes Penicillum,
Aspergillus, Cladosporium, Stachybotrys Species ID & Count)
M009 Bacteria Culture Gram Stain & Count
M010 Bacteria Count & ID - 3 Most Prominent
M011 Bacteria Count & ID - 5 Most Prominent
Special Instructions and/or Regulatory Requirements (Sample Specifications, Processing Methods, Limits of Detection, etc.)
Method of Shipment:
Sample Condition Upon Receipt:
Relinquished by: Received by: Date/Time
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.
State of Connecticut (CT) must select project location:
Project Information
Purchase
Order:
MICROBIOLOGY TEST CODES
Temperature
(Lab Use Only)
Date / Time Collected
Volume/Area
1,000 ml
1/1/2021 3:30pm
M031 Rapid-growing non-TB Mycobacteria Detection &
Enumeration
Company Name:
Contact Name: Billing Contact:
Project
Name/No:
Sterile, Sodium Thiosulfate Preserved Bottle Used: Biocide Used in Source (specify)
Public Water Supply Samples: Note: All results may automatically be reported to DOH if required by State.
Zip Code
Samples
Collected::
Kitchen
Sample # Sample Location/Description
Sample Type
(Matrix)
Potable /
Non-
Potable (Only for
Water)
Test Code
Water
Example: Sample 1
Potable
M017
Microbiology Chain of Custody Form
EMSL 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:
Customer Information
Email(s) for Invoice:
Billing Information
City, State, Zip: City, State, Zip: Country:
Phone: Phone:
No. of Samples
in Shipment
Relinquished by: Received by:
Page 1 of
EMSL LIMS Project ID:
(If applicable, EMSL will
provide)
Turn-Around-Time (TAT)
24 Hour 48 Hour 72 Hour 96 Hour 1 Week 2 Week32* Hour3 Hour 6 Hour
Please call ahead for large projects and/or turnaround times 6 Hours or Less. *32 Hour TAT available for select tests only; samples must be submitted by 11:30am.
PHONE:
EMAIL:
AGREE TO ELECTRONIC SIGNATURE (By checking, I consent to signing this Chain of Custody document by electronic signature.)
Commercial (Taxable)
Residential (Non-taxable)
