Basic HTML Version
SOP10 – Toxicity Analysis
80
11.5. Datasheets
SAMPLE CUSTODY FORM
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EFFLUENT/RECEIVING WATER RECEIPT
The University of Maryland/Wye Research and Education Center
State of Maryland Effluent Testing Facility, Queenstown, MD 21658
Facility Name:
__________________________________________________________________
Address: __________________________________________________________________
Permit No. __________________ Outfall No.____________ Sample ID. No. ______________
Collected by:_______________________________________________________
Sample Type:
Grab: Collected ____________; ____/___/_____
(Time)
(Date)
Grab Series: Collected from: __________; ____/___/_____
(Time)
(Date)
to: __________; ____/___/_____
(Time) (Date)
Total No. Grab Samples: __________________
Sampling Interval: _______________________
Composite: Collected from: __________; ____/___/_____
(Time)
(Date)
to: __________; ____/___/_____
(Time)
(Date)
Sample cooled:
During collection- (Y ),(N ); Initial
During delivery- (Y ),(N ); Initial
During receipt- (Y ),(N ); Initial
On site Effluent Physical/Chemical Measurements:
Conducted by: _________________Date/Time: ____________________
pH:_____________
Dissolved oxygen (mg/L): ________________
Temperature (° C): ______________
Salinity (‰): _______________
Conductivity ( mhos): ____________
Chlorine (mg/L) (free)_________; (total)_________
Comments: _________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Sample possession:
From:___________________ To: __________________
(Name-Date-Time) (Name-Date-Time)
From:__________________ To: __________________
(Name-Date-Time)
(Name-Date-Time)