Country: Email(s) for Report: Sampled By Name: Sampled By Signature: Date/Time: Date/Time: Controlled Document - COC-31 Crypto/Giardia R9 3/18/21 Please use COC-75 Aquatic Microbiology for Microscopic Particulate Analysis (MPA). Client Sample ID Test Code Date/Time Sampled Sample Type Volume Filtered (Liters)* Filter Clog?* Number of Filters* Field Filtered Samples Temp Acceptable During Transport? (0-20°C for crypto) Lab Use Only PWS ID: Facility ID: Collection Point ID: Source ID: • M640 Cryptosporidium and Giardia (EPA 1623.1) • M114 E. coli (MPN by SM 9223B) • M641 Matrix Spike for Cryptosporidium and Giardia (EPA 1623.1) Relinquished by: Received by: Special Instructions and/or Regulatory Requirements (Sample Specifications, Processing Methods, Limits of Detection, etc.) Packing (place the temperature strips or logger into the coolers) Name: Date/Time No. of Samples in Shipment TAT (Turnaround time): 1 Week 2 Week Other (Specify): Please fill one sample per row. • Please collect 10 liters water for each LT2 cryptosporidium compliance sample. • Cryptosporidum samples will be rejected if hold time > 48 hours, if sample temperature exceeds 20°C or is frozen, or if samples leak. • E. coli samples must be shipped as soon as possible as the hold time is 30 hours, and the acceptable temperature is 0- 10°C upon receipt. • For swimming pool water (non-LT2), please submit 1 liter backwash water. • Please contact lab about sampling for any other water bodies. Temp. upon Receipt (°C) LT2 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: Billing Contact: Purchase Order: City, State, Zip: City, State, Zip: Country: Phone: Phone: Project Name/No: US State where samples collected: State of Connecticut (CT) must select project location: Project Information Customer Information Email(s) for Invoice: Billing Information EMSL LIMS Project ID: (If applicable, EMSL will provide) Test Codes Company Name: Contact Name: 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. Method of Shipment: Sample Condition Upon Receipt: Relinquished by: Received by: Date/Time Page 1 of PHONE: EMAIL: Commercial (Taxable) Residential (Non-Taxable) Regular Matrix Spike Regular Matrix Spike Regular Matrix Spike Regular Matrix Spike Regular Matrix Spike Regular Matrix Spike Regular Matrix Spike Regular Matrix Spike Regular Matrix Spike Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No Yes / No AGREE TO ELECTRONIC SIGNATURE (By checking, I consent to signing this Chain of Custody document by electronic signature.)