Mid-Atlantic Environmental Laboratories, Inc.



Bottle Order Request

No.      

Date of Request:       Time of Request:      

Client:      

Person making request:      

Phone Number:       Date bottles are required:      

Location of bottle drop off:      

Sample Matrix: Groundwater Soil Wastewater Stormwater Drinking Water Other (specify)      

Analysis/analyses to be performed:      

State where sample will be collected: NJ PA DE MD Other (specify)      

Project Name:       Regulatory Program:      

Number and size of bottle requested:

Quantity Preservative Quantity Preservative

5 g EnCore             60 ml plastic            

1 liter amber glass w/TLC             250 ml plastic            

32 oz wide-mouth glass w/TLC             500 ml plastic            

4 oz. plastic cup             1000 ml plastic            

40 ml vial             2 oz glass jar w/TLC            

40 ml vial             4 oz glass jar w/TLC            

40 ml vial – Field Blank             8 oz glass jar w/TLC            

40 ml vial – Trip Blank             16 oz glass jar w/TLC            

VOA vial foam sleeve       please return foam sleeves to lab

Rinse water: Yes No Quantity: Liter       Gallon      

Additional information:      

Bottle labels provided with bottle request. Chain of Custody available online; hardcopy available upon request.

Extra sample bottles (if included) are for sample duplicates and/or matrix spikes. These are essential elements of MAEL’s QA/QC program, and required by most regulatory authorities. Please provide extra sample when possible. Thank You!

Please return unused bottles!

Bottles prepared by: _________________________________________________ Date: _______________________

Bottles delivered by: _________________________________________________ Date: _______________________

Bottles received by: _________________________________________________ Date: _______________________

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