Chain-of-Custody-Form

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Mold Mart Mold Laboratory

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

____________________________________________________________ _____________
Signature of Inspector or Client Who Collected the Above Samples Date

Released by __________________________________ on Date & Time______________ by sending

the above samples to _________________________________________________________________.

by ___Mail: ___Fed Ex ___UPS ___Airborne Express ___ DHL ___Other: _________________

with a tracking number of:______________________________________________________________

Lab Acknowledgement of Receipt of Samples
Received by________________________________________ on Date & Time___________________

at ______________________________________________________________.

(Printed from: http://www.moldmart.net/chain_of _custody_form.htm)

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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.

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