*Pace Location Requested: City and State of Pace Laboratory testing is to be performed at. Click Here for Pace® Lab Locations

*Company Name: Client’s company name

*Street Address: Client’s mailing address

*City, State, Zip: Client’s city, state and zip code for mailing

*Contact/ Report to: Person to receive results

Customer Project # and Project Name: Client’s reference to the project or work involved with these samples

Site Collection Info/ Facility ID: Client’s location of project

Time Zone: Check time zone of sample to ensure proper hold times are met

Purchase Order #: Client specific number to be listed on project invoice for client billing purposes

Invoice To:  Client contact the project invoice needs to be emailed to.

Invoice Email:  Email address that project invoice will need to be emailed to

*Phone #: Client’s contact phone number

E-mail: Client’s e-mail for correspondence and final report

Regulatory Program: List the program that is guiding the work to ensure proper regulations are followed:  DW, RCRA, etc

Data Deliverable: Please select or enter required deliverables

*County/State Origin of Samples: Enter the county to ensure proper handling of regulated soils.  State required to ensure proper reporting.

Field Filtered:  Indicate if samples have been filtered in the field.  If samples are required to be field filtered and filtering is not indicated a qualifier will be added to all associated data.

 

 

Rush request: If faster than standard turnaround time results are needed. Circle one of the rush options and note the day the results are requested by. All rush requests require preapproval by the laboratory.  Surcharges will apply for non- standard turnaround times.  Results will be due by end of business on the date due based on standard turnaround time unless other arrangements have been made with your Project Manager.

*Customer Sample ID: The unique sample ID you want to appear on the analytical report

*Collected Date: Date sample was collected. For composite samples, please fill in both beginning and end date.

*Collected Time: Time sample was collected. For composite samples, please fill in both beginning and end time.

*Suma Canister ID: The unique ID assigned to the summa canister used.

*Flow Controller ID:  The unique ID assigned to the flow controller used.

*Matrix: Select from list provided list. If prepopulated chain is provided for you matrix codes may vary.

*Canister Pressure/Vacuum: Record the start and end pressures for each canister.

*PUF/Filter: Record Duration, flow rate and total volume sampled.

 

*Analysis Requested: Write the analysis name (or an abbreviation), the name of a group of tests, or the method number you would like us to perform. Examples are BOD, TCLP Metals, PCBs, Method 624, etc. Place a check mark in the small boxes that correspond to the sample(s) on which you want these tests performed.

Sample Comment: List any notes or important information about the individual sample here.

Customer Remarks/Special Conditions/Possible Hazards: List special instructions about the sample here.  If the sample is known or suspected to be hazardous indicate that here and attach SDS if possible.  This space can also be used for listing additional analyses, or to request an extra copy of the report to be sent to an alternate person/address, etc.

Summarized Sample Acceptance Policy Requirements:

  • Proper, full and completed chain-of-custody documentation
  • Readable unique sample container identification written in indelible ink
  • Appropriate sample container
  • Sufficient sample volume to perform requested tests
  • Received within required holding time
  • Received within temperature preservation requirements
  • Sample containers received in good condition (not leaking or broken)
  • Any custody seal intact
  • Properly preserved
  • No headspace in volatile water samples

A data qualifier and/or case narrative will be added to the final test report when the above sample acceptance requirements are not met.

Location Specific Sample Acceptance Policy available from your Project Manager

*Relinquished By/Received By: This form must be signed each time the sample(s) changes hands. Custody seals are available upon request if needed.

*Required field: Failure to fill in a required field may result in a sample(s) being put on hold until information can be obtained.  This may result in a delay in receiving results.