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ED <br /> INTERNATIONAL 9/ / I U '4 U <br /> TECHNOLOGY CHAIN-OF-CUSTODY RECORD R/A Control No. 21 � <br /> CORPORATION <br /> ---�-� I C/C Control Na. 265177 <br /> PROJECT NAME/NUMBER ��� �T�CIL tJ ��(Oa9Z.Z LAB DESTINATION MQA ---r" <br /> SAMPLE TEAM MEMBERS CARRIER/WAYBILL NO. <br /> Sample Sample Date and Time Sample Container Condition on Receipt Disposal <br /> Number Location and Description Collected Type Type (Name and Date) Record No. <br /> Oq A <br /> /UA <br /> t t 10 <br /> /Z/0- u l <br /> /3R kkassp is 1040 <br /> /qA 1 11 <br /> /SA <br /> /GSA uoSS ll4p <br /> r 7A l l50 <br /> Special Instructions: 2 I In,,- <br /> Possible Sample Hazards: <br /> SIGNATURES: (Name, Company, Date and Time) <br /> 1. Relinquished B — ZT� Il I6�91 3. Relinquished By: <br /> Received By: k k—� ( Q / Received by: <br /> 2. Relinquished By: 4. Relinquished By: <br /> Received By: Received By: <br /> WHITE-To accompany samples <br /> YELLOW-Field copy 127A-10-85 <br />