Mold Inspector Laboratory Int'l, Ltd.
This form will be sent to you together with your mold samples to the address specified in your official receipt.
Email: moldconsultant@yahoo.com or visit Mold Inspector Website.
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MOLD CHAIN OF CUSTODY
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The mold chain of custody is a mold laboratory form which is completed by the
property owner or manager, or by the Certified Mold Inspector, who collects the
mold samples to record the details of the mold sampling work done, and to
document both the transfer of custody of the mold samplings directly
from the inspector to the mold lab, and their receipt by the lab.

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Inspector name [if any] ____________________________________________________________________

Client name ______________________________________________________________________________

Client mailing address:_____________________________________________________________________

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Client Daytime Phone: (______) _______________________ Client FAX (______)____________________

Client Email:____________________________________ Date of sampling__________________________

Sampling address__________________________________________________________________________

Type of laboratory mold analysis to be performed: ___ viable testing ___non-viable testing

Test Type Numbers:
1 for bulk physical or direct mold sample; 4 for mold culture plate fan method;
2 for mold culture plate settling method; 5 for mold culture plate hvac fan;
3 for mold culture plate impactor; 6 for air cassette sample;
7 other method, please specify:_____________________________

Sample Specific Sampling Test Type Time On Time Off Notes
ID # Location

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Signature of Inspector or Client Who Collected the Above Samples Date

Released by __________________________________________ on Date & Time___________________ by

sending the above samples to _______________________________________________________________,

by: ___Fed Ex ___UPS ___Airborne Express ___ DHL ___ Other:_________________________________

with a tracking number of:___________________________________________________________________

PLEASE DO NOT SEND MOLD SAMPLES VIA US POST OFFICE WHICH IRRADIATES

PACKAGES TO KILL POSSIBLE ANTHRAX SPORES FOR POSTAL WORKER SAFETY.

Received by___________________________________________ on Date & Time______________________

at _____________________________________________________________________________________.

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