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q � � ` �` �` ERMMEN7 <br /> TASSESSORS INC. 7 <br /> � j <br /> Custody Transfer Record/Lab Work Request <br /> Retri eratortl LAB USE ONLY <br /> #/Type Container Samples Were <br /> Client -��{ _ -- Volume 1 Shipped or Hand <br /> Work Order �D 7 0.l ® ��� Delivered�� Preservative NOTES <br /> Date Recd Date Due <br /> ANALYSES If <br /> /t D✓Wb,t.i Spy REQUESTED �` r} 2 Ambient or Chilled <br /> Client ContacVPhone - _ NOTES <br /> Client 1DIDescri tion Matrix Date <br /> LabiD <br /> Collected 3 Received Brokery <br /> 1 44 1S 5fa Leaking (Improperly <br /> Sealed) <br /> Y N <br /> 3 C'J NOTES <br /> a Propprly Preserved <br /> —�- NOTES <br /> 3� 5 Received Wits)in <br /> Holding T[cups <br /> ��J ------ — --- -- — - --- -- — Y N <br /> NOTES <br /> (L _ COC Tape Was <br /> 1 Present on Outer <br /> Package Y N <br /> y ^ r { 2 Unbroken on Outer <br /> b Parraoe Y N <br /> 3 Present on Sample <br /> Y N <br /> Metrix W Water DS Drum Solids X Other Special Instructions 4jF-- G,rr- a Unbroken on Sample <br /> S Soil 0-011 DL Drum Liquids n � "'� �Y-� NOTES Y N <br /> SE Sediment A Air F-Fish <br /> SO•Solid Wt•Wipe L EPITCLP Leachate <br /> Item/Reason Relinquished b Received by, Date Time Item/Reason Relin unshed b Received by Date Time COC Record Was <br /> 1 Present Upon Receipt <br /> 0 rn of Samples Y N <br /> Discrepancies Between <br /> _ Sample Labels and COC <br /> Record) Y N <br /> NOTES <br />