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• - � <br /> Chain-of Custody Number <br /> SECQR. Chain-of Custody Record � <br /> 0K A Additional documents are attached, and are a part of this Record <br /> Field OfficeC-1�' <br /> Job Name '0 <br /> Address 1:140 W���pW S r2 � 44<> <br /> c r {�- Location <br /> Analysis Request <br /> Project# HOQo ~ Task k�_ <br /> Project Manager <br /> DC 7 6 <br /> Laboratory = ;, E <br /> Turnaround Time C' v o ,Q q� f U <br /> o rnU v m(UV7 � / o <br /> Sampler's Name t `� 61n <br /> Q � E E m 'Mo = a=7o �� �a -fl— S ti E <br /> 4 z <br /> Sampler's Signature a' 33 < `0%�7 �'@ o m @ '' kmientl <br /> _ x oa mn mN n7 oa �' <br /> Sam le IO Date Time Matrix (3 rte-m w$ y a m �° z w a m a 8 P 7, a� � Instructions <br /> F <br /> 1021Sttfl <br /> w <br /> Act, <br /> cat <br /> Relinquished b 5 Receive y Sample Receipt ; <br /> Specrat Instructions/Comments y Total no of containers <br /> Sign Sign a <br /> Print <br /> "Va Prrni Chain of custody seals <br /> Comp112Z._ <br /> Recd in good conditionicold <br /> Compante Time Date 9 c"lorms to rewd <br /> linquished by Re d by Client - <br /> Sign Sign <br /> Print Print -- Client Contact <br /> Company ti Company Q�6 364�� <br /> Time Date-/``Time Date Client Phone <br /> Sfipl7RCU57R£GAEriN6 Q(? 1d �((I r, L__ <br /> f!,(„ Lr I � Date �� �� PagP �of� - <br />