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