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Chain of Custody Record - Page —/– of <br /> Company Name Project Manager/Contact Special QA/0C Protocol PARAMETERS FOR ANALYSIS <br /> Galson (circle) <br /> EPA CLP EPA SW 846 D '� <br /> �� ;,�e,"�f "S`,��'`« �.``�-r .�•�•� Laboratories <br /> Project No Protect Name v NYS DEC NYS <br /> 6601 Kirkv,lle Road East NJTIER I ALII=0RN1 <br /> E Syracuse, New York 13057 << <br /> 315-432-0506 or 800 950-0506 NJ TIER 11 OTHER(Specify)1 <br /> TYPE o Laboratory <br /> SAMPLE LOCATION/SAMPLE 10 Date TimeE _ ID 1 <br /> 8 c� Cr Q t o <br /> A B C D E F G H I J K Number <br /> [ 1 1 Ifa�J k F1r Lfitl it liir r1 1/ a4 w)I <br /> nr lli� <br /> �rlq lnrj rlrl r4o1n 4i 4 Z fIi'l <br /> yly <br /> 24-1 4rA L W4 ITt. <br /> Engtneer�nq ':�c, encF- 471-i4—(}04 <br /> f <br /> ,ep -24-19'�l Water I# ?F bi ANK <br /> i <br /> Ei <br /> `I <br /> r , <br /> REMARKS t,r� C rw f U._ �a.�, /L' / �.�c+� Task No <br /> I <br /> I <br /> SAMPLERS SIGNATURE <br /> NAME 2 <br /> SAMPLES RELINQUISHED BY SAMPLES RECEIVED BY Received For Laboratoryy DATE <br /> NAME i c U.� <br /> i DATE y��"� NAME DATE {Signature) TIME 1()()5' <br /> SIGNATURE TIME j' SIGNATURE TIME Custody Seal Intact?Sample [:] Yes ❑No O N A � <br /> NAME DATE NAME DATE Shipment Complete? ❑ Yes ❑W <br /> SIGNATURE TIME SIGNATURE TIME f(R <br /> tor A B C D E F G H I J K L N <br /> NAME DATE NAME DATE ion <br /> SIGNATURE TIME SIGNATURE TIME #) <br /> t� <br /> _ 1 <br />