DO IT YOURSELF Toxic Black Mold & Environmental Hygiene Inspection, Testing, Remediation, & Prevention Products & Services Available from Mold Mart™ since 2002
For product info & help, please email: envirodangers@yahoo.com
or phone 6017-898-5048 (Malaysia international office)
or 1-480-310-7970 (USA shipping office)

EnviroDetectives™ CHAIN OF CUSTODY
form for Mold Test Kits, Surface Samplers, Scotch Tape Lift Sample and Bulk Sample

This chain of custody is the EnviroDangers™ mold laboratory form that is completed by the tester (property owner, manager, or agent or employee thereof, or mold inspector or environmental hygienist), who takes the mold samplings with Surface Samplers, and who records the details of each sampling on this form. This form also serves to document both the transfer of custody of surface samplers directly from the tester to the mold lab, and the mold lab's receipt of your mold samples. Please mail the collected Surface Samplers and this completed Chain of Custody form to the mold lab, along with your EnviroDangers™ payment receipt. Please print the requested info below with a black ink pen legibly because the information you provide will be included in the mold lab report as to each sampling location.

EnviroDangers™ email: envirodangers@yahoo.com Phone: 1-480-310-7970

Tester’s name: ___________________________________________________________________________

Client name: _____________________________________________________________________________

Signature: ______________________________________________________ by □Tester    □Client
The contact information provided below is for the:   □Tester    □Client

Address:_________________________________________________________________________________

Daytime phone: (________) _______________________        FAX (________) _______________________

Email address:____________________________________________________________________________

Date of sampling: ____________________   Time of day of sampling: _____________

Sampling property address__________________________________________________________________

_________________________________________________________________________________________

Type of laboratory mold analysis to be performed on the Surface Samplers, Scotch Tape Lift Sample and Bulk Sample:
□ non-viable/direct examination analysis (2 day mold species identification and combined counts of both
      live and dead mold spores). This is the quickest mold lab result. Lab fee $50 per sample.
□ viable/cultured growth of samples for 5 to 7 days (mold species identification and count of grown/live
      mold colonies). This is the best method for accuracy of mold species identification, but it takes at least
      5 to 7 days of mold culture growth, plus one or two days for mold lab analysis time. Lab fee
      $60 per sample.

Sample Number	Precise location/description in which the sample taken	Notes to include in mold lab report
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