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r r r f f r r r f r r t r 11 r - r r <br /> EoL�o�� ANALYSIS REQUEST AND Reference Dgcurnent No. 3 7 3 571 <br /> COMRAMON (�,y(,} HAIN OF CUSTODY RECORD* Page 1 of ` <br /> Project Name/No.?�A� B I __n'�_ amples Shipment Date 7 5 /2- �No _ Bill to-5 <br /> Sample Team Members 2 A0 Sm I (^ Lab Destination 8 a1-Si -- <br /> Profit Center No. 3 c��T ,�1+� Ad"Contact 9 `�" imovirion <br /> SS I <br /> Project Manager Syr,)&vH 6"c e k Project Contact/Phone t2 J Yd^ Cecls 51D 3-fZ`1100 <br /> Report to:t0 �l <br /> Purchase Order No.6 65 }yg Carrier/Waybill No. 13 <br /> Required Report Date 11 <br /> rr 6still <br /> I <br /> Sample 14 Sample 15 Date/Time 16 Container) Sampler E pre- 19 Requested Testing 20 Condition on 21 Disposal 22 <br /> Number Description/Type Collected Type Volume seruative Program Receipt Record 4N <br /> 55A- EMA,-oo1 5 , L- cY<Ie SIZ 96123 S�lru� Zu �f3 Sk TPl �psa(� <br /> 551 EMR- O0 7- <br /> 123 <br /> i <br /> SS 9 fu 003 I <br /> SSA E W1K ov 12C <br /> SSd t r>7r4-[>o5 <br /> f5wss 4x TO -yes/ Tp lrse r ► -x <br /> 5�1°- reMf-to � ' 13`1 le..r.e 1l „at Pb Rez <br /> SIl° - E W1R -0o `� I3 4FO <br /> I <br /> Special Instructions: 23 <br /> Possible Hazard Identification: 24 Sample Disposal: 25 <br /> Non-hazard IJ Flammable iJ Skin Irritant ',J Poison B iJ Unknown Return to Client J Disposal by Lab Archive_ (mos.) <br /> Turnaround Time Required: 26DC Level: 27 <br /> Normal RushlJ I-IJ 111J 110JI ProjectSpecific [specify); _ <br /> 1. Relinquished b 28 Date: 5�12. 196 <br /> 1. Received by 28 Date:__ <br /> (Signature/Affiliation) Time: ]y (Signature/Affiliation) Time: <br /> 2. Relinquished by Date: 2. Received by Date: _ <br /> (Signature/Affiliation) Time: (SigneWm/Affiliatun) 17Time: <br /> 3. Relinquished by Date: 3. Received by _ Date:_ z <br /> (Signature/Affiliation) Time: (signature/AffiliadonJ <br /> Time: <br /> C/ / <br /> Comments:29 VC <br /> v <br />