Submitting a Sample

Chain of Custody form

Print this and include it with every sample shipment. The Lab Log # at the top is filled in by us at receipt — leave it blank.

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CHAIN OF CUSTODY RECORD

SCISSORTAIL

ANALYTICAL SOLUTIONS

LAB LOG #

for lab use — assigned at receipt

8200 N. Classen Blvd, Suite 110, Oklahoma City, OK 73114 · 405-590-4880 · testing@scissortail-lab.com

Submitted By

Customer / Company

Operator

Contact Name

Phone

Report Results To (if different from above)

Sample Information

Sample Matrix / Type

Produced / Treatment Water Solid / Deposit / Residue Treatment Chemical Other: ______________

Priority

Standard (5 business days) Rush (24 hours)

Date / Time Received by Lab

Received By (Lab Staff)

Sample Log

Lab Sample ID	Sample Name / Description	Well Location	Sample Location	Test(s) Requested	Date/Time Collected	Notes

Common Test Reference

Water & Benchtop Chemistry

CWA — Complete Water Analysis

TSS — Gravimetric Solids

MPA — Millipore Analysis

ATP

Instrumental & Materials

XRD — X-Ray Diffraction / clay speciation

FTIR — Infrared Spectroscopy

Product & Surface Testing

Scale / Corrosion Inhibitor Screening

Paraffin Solvency / Dispersancy

General Solvency · Biocide / Microbial Kill

Surface Tension · IFT · Contact Angle · Surfactant Screening

Sample Handling Reminders

1. Label every container with a sample ID, collection date, and location. 2. Record the date, time, and location for each sample above. 3. Keep temperature-sensitive samples chilled in transit. 4. Include this completed form with every shipment.

Chain of Custody

Relinquished By (Customer)

Signature

Print Name

Date / Time

Received By (Scissortail Analytical Solutions)

Signature

Print Name

Date / Time