CLIENT: ADDRESS:	POINT OF CONTACT:	PROJECT NO:
PHONE NO: E-MAIL:	LAB NO:
TURNAROUND TIME / SPECIAL INSTRUCTIONS / COMMENTS:	EAGLE NO:
JOB SITE / DESCRIPTION:
ANALYTE:	SAMPLE TYPE: MEDIA:	ANALYTICAL METHOD:
FIELD SAMPLE NUMBER	SAMPLE LOCATION / DESCRIPTION	VOLUME/AREA ( )
COLLECTED BY:	DATE:	RECEIVED BY / CHAIN OF CUSTODY INITIATED BY:	DATE:	TIME:
RELINQUISHED BY:	RECEIVED BY:	DATE:	TIME:
RELINQUISHED BY:	RECEIVED BY:	DATE:	TIME:
SUBMITTED TO LAB BY:	DATE:	RECEIVED AT LAB BY:	SAMPLES:	DATE:	TIME:
FOR LAB USE ONLY
PRE-LOGGED BY:	PREPARED BY:	ANALYZED BY:	DATE:
DATA VALIDATED BY:	RUSH REPORT BY:	POST-LOGGED BY:
DATA PROCESSED BY:	TEST REPORT REVIEWED BY:	TEST REPORT APPROVED BY:	DATE:

Rev. 8-28-17 Industrial Hygiene Associates, Inc. Page 1 of ____ CHAIN OF CUSTODY RECORD RECORD 359 Dresher Road Horsham, PA 19044	215-672-6088 office 215-443-0899 fax www.eagleih.com