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cy Ilii. r r EI R ] 1 T A E I M I �Imr- } _ <br /> Custody Transfer Record/Lab Work Request <br /> n_,, Relri erator# LAB USE ONLY <br /> CQ,e5 #rT e Container Samples Were <br /> Client Volume t Shipped or Hand <br /> Work order �� Delivered <br /> Preservative <br /> Date Rec'd Date Due ,PCS ��"�' NOTES <br /> ANALYSES4� <br /> �►�y�+.es.L S'qG,-a REQUESTED �1 2 Ambient or Chilled <br /> Client ContactrPhone – ,...__ (� NOTES <br /> I <br /> Client ID/Description Matrix Date <br /> Lab ID Collected 3 Received Broken, <br /> SB/S- 77 IF-P-3 L ll Leaking (Improperly <br /> Spaled) <br /> Z S Y N <br /> ` T3 NOTES <br /> 4 Properly Preserved <br /> Y N <br /> S NOTES <br /> _ 5 Received Within <br /> 3 S o-19`13 Holding Times <br /> 10 <br /> _ NOTES <br /> il <br /> C Tape Was <br /> 11 SS CO Present on Outer <br /> 13 _ G Package Y N <br /> 1 6 S 2 Unoken Package on Outer N <br /> I 7V3 Present on Sample <br /> Y N <br /> Matrix W Water DS Drum Solids X Other Special Instructions 4 Unbroken on Sample <br /> S Soil O-oil OL Drum Liquids �l <br /> SE Sediment A-Air F Fish � _ COY iGT,--re S `Gtt:7q/A-Z �-/�►t -YP S_- NOTES Y N <br /> SO Solid Wl-Wipe L EPITCLP Leachate ll `�� _ <br /> COC Record Was <br /> ItemlReason Relin uished by Receive-d-by Date Time Item/Reason Relm unshed by Received by Date Time t present Upon Receipt <br /> C � <br /> - L(Jof Samples Y N <br /> lvvri Discrepancies Between <br /> Sample Labels and COG <br /> Record? Y N <br /> NOTES <br />