LABORATORY ANALYSIS REQUEST PAID
Client/Billing Information
Sample Information (If Different)
or Licensed Inspector Collected) Report Receipt (US Mail if no email or fax provided)
By: Official COC
6121 North Hanley Road • Berkeley, MO 63134 • PH 314/615-8324 • FAX 314/615-1648 • https://stlouiscountymo.gov/ FRM 14.4.1 Revision: 7 7/24/23
BILL The Client bears full responsibility for proper sampling technique and accurate sample information. The lab reserves the right to refuse receipt or analysis of any improperly labeled, packaged, or transferred sample.
Name/ Company: Name/ Company: Address: Address: City: State: Zip: City: State: Zip: Phone: Location: Comments: Collected
Fax
Relinquished: Date: Time: Received
Relinquished: Date: Time: Office Received: Lab Received: Date: Time: Lab Comments: Water Samples (Water Type) Testing Requested Microbiology (lab supplied bottle): Radiochemistry: Metals: Env. Lead Dust Wipe Paint Chips Soil Tape Lift for Mold/Pollen Miscellaneous (Fill in Below: Sample Type and Testing Request)
Gray Area –
Laboratory Sample ID or Bottle # Sample Description or Location Date Collected Time Collected Initials Collector Sample Condition (A/U) Log # Date Completed Analyst Initials Report Approved By: Date Approved: Other Coliform/Fecal Gross Alpha Filter Lead Radium 226 Radium 228 Uranium Iron Copper Asbestos in Building Materials
(County
Email or
#: Chain-of-Custody
By:
Please fill information for each sample submitted
For