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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.
_________________________________________________________________________________
MOLD CHAIN OF CUSTODY
_________________________________________________________________________________________
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.
_________________________________________________________________________________________
Inspector name [if any] ____________________________________________________________________
Client name
______________________________________________________________________________
Client mailing
address:_____________________________________________________________________
__________________________________________________________________________________________
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
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_______________________________________________________ _____________
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
_____________________________________________________________________________________.
______________________________________________________________________________
•Please
click here to view a printer-friendly copy of the Mold Chain of Custody a
new page. •
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