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If r r r r r r r rINTERNATION <br /> r r r r r r r <br /> TECHNOLOGYYAL ANALYSIS REQUEST AND Reference Document No. 5 7 i <br /> CORPORATION � � � � C AIN OF CUSTODY RECORD* Page 1 of � <br /> Project Name/No. /Rc &(I S�)mples Shipment Date S / 3 1� Bill to:5_._ <br /> Sample Team Members-2 �TI S tti , Lab Destination 8 0d• Si/e SpAra o,r - <br /> Profit Center No. 3 .TT n4 f2 Lab Contact 9 /4/lot, ��ornSoti <br /> Project Manager4 Sy-fKey G� k Project Contact/Phone 12 5y 16 c jt Fo 372 WOO <br /> tQ <br /> Reportto: <br /> Purchase Order No.6 �6 S `�$ Carrier/Waybill No. 13 — <br /> Required Report Date 11 2 ' <br /> Sample 14 Sample 15 Date/Time 16 Containers Sample Pre- 19 Requested Testing 20 Condition on 21 Disposal.22 <br /> Number Descri tion/T Collected Type Volume servative Pro ram Receipt <br /> }� SSeob S��L Iscarrf oo e 2X, (�� rPwt 1 <br /> D5E' r� <br /> SSS-t (o <br /> Ar <br /> �Slh wiR00 <br /> b-e- k1 - <br /> Cv 15 I' 61 TAL 6 IQGT- <br /> I <br /> Special Instructions: 23 <br /> Possible Hazard Identification: 24 Sample Disposal: 25 <br /> Non-hazard IJI Flammable iJ Skin Irritant J Poison B IJ Unknown Return to Client IJ Disposal by Lab Ir Archive_ (mos.) <br /> Turnaround Time Required: 28 DC Level:27 s <br /> Normal IJ Rushy l I.IJi 111J lll.rj Pro'ect Specific (s ec ): <br /> 1 . Relinquished b 28 7 � ate: 6 1. Received by 2e Date: <br /> [Signature/Affiliation) • 1 CO/I <br /> /C i Mme: Hob [Signature/Affiliation) Time: i <br /> 2. Relinquished by Date: 2. Received by Date: <br /> (Signature/Affiliation) Time. (Signature/Affiliation) <br /> Time: <br /> 3. Relinquished by Date: 3. Received by l_ Date: c,- <br /> Time: 3 - <br /> (SigneWre/Affiliation) [Signature/Affiliation) - <br /> Comments:29 as ,V01r � Time: Oe) <br /> /-' <br /> �� <br /> /I i 391 <br />