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INTERNATIONAL ANALYSIS REQUEST AND �rl Reference Document No <br /> TECHNOLOGY /�J/7 �7 CHAIN OF CUSTODY RECORD* Page 1 of s <br /> CORPORATION <br /> c 7 l/-/� -�`� BILI to 5 %T Cxa�� _ __ _ _ _ - 19 <br />` ��%ampler Shipment Date <br /> Project Name/No _ <br /> �.bn1 Lab Destination <br /> Semple Team Members �_ '`�--- s <br /> 3 z/I Z!d Lab Contact <br /> Profit Center No �c� <br />+ a �' G Project Contact/Phone 1;0,`'��r7�' Report to 10 <br /> Project Manager _ - _ - ` <br /> Purchase Order No <br /> s ----� Carrier/Waybill No 13 A-)11-2 <br /> 7 <br /> Required Report Date " !/�/�� -�/`l � � + - - N <br /> 1 Sam le 1 Pre- �9 Requested Testing 20 condition on 21 Disposal 22 <br /> Sample 14 Sample 15 Date/Time, Container Voluma aervatIve q Program <br /> Races t Record Na <br /> Number Description Collected T e m <br /> �/LSinJ�. <br /> �C�/L N-/(a /3G>� Vic f T <br /> a � <br /> r 5 <br /> Cr <br /> d <br /> 3 j <br /> S eciai Instructions 23 <br /> Possible Haz jdentification Sample Disposal 25 i <br /> Nanfiaxard► Fjammahte l Jl Skin irritant ;�1 Poison 8 l J Unknown J Return to Client J Disposal by Lab ` Archive <br /> ]mos 3 i <br /> �7 <br /> Turnaround Time Required 26 DC Level <br /> z� <br /> Norma] I.J Rushy J I I J 11�,J ill Al Pro ect Specific (s e i � i <br /> �— -41 <br /> Date !/��^ r` 1 Receive y L� Date f <br /> 1 Relinquished by�� Time ' <br /> ISignoture/All�kation i <br /> (` /Af Lhauon) - Date <br /> 2. Relinquished by _ Date 2 Received b Time <br /> [Sipnapur+a/Athkaunn! Time (signature/Alfiliauon) <br /> Date 13 Received by Date <br /> 3. Relinquished by Time — - (signature/Afhliaunn) Time <br /> l8gnnrr/A1 <br /> Comments 29 <br /> MCA 3,1 SIJ 1 <br />