Country:
Email(s) for Report:
State
Samples
Collected:
Sampled By Name: Sampled By Signature:
Date/Time:
Date/Time:
Controlled Document - COC-35 Moldview R7 02/26/2021
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.
Special Instructions and/or Regulatory Requirements (Sample Specifications, Processing Methods, Limits of Detection, etc.)
Method of Shipment:
Sample Condition Upon Receipt:
Relinquished by:
MoldView 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:
Project Information
Customer Information
Email(s) for Invoice:
Billing Information
Sample #
EMSL LIMS Project ID:
(If applicable, EMSL will
provide)
Company Name:
Contact Name: Billing Contact:
Project
Name/No:
Purchase
Order:
City, State, Zip: City, State, Zip: Country:
Phone: Phone:
No. of Samples
in Shipment
State of Connecticut (CT) must select project location:
Date / Time CollectedVolume/Area
M041 Direct Exam
(Tape, Bulk, Swab Matrix)
Sample Location/Description
Example: Sample 1
Kitchen
Zip Code
Samples
Collected:
Date/Time
Relinquished by: Received by:
100L 1/1/2021 - 3:07pm
Received by:
Page 1 of 2
Turn-Around-Time (TAT)
*32 Hour TAT - Samples must be submitted by 11:30am.
24 Hour 48 Hour 72 Hour 96 Hour 1 Week 2 Week32* Hour3 Hour 6 Hour
Commercial (Taxable)
Residential (Non-Taxable)
PHONE:
EMAIL:
M165 MoldView
M166 Pre-Paid MoldView
(Select One - Air Matrix Only)
If submitting Pre-Paid Cassettes, select M166 below.
If not submitting Pre-Paid Cassettes, select M165.
AGREE TO ELECTRONIC SIGNATURE (By checking, I consent to signing this Chain of Custody document by electronic signature.)
