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OR r G ' <br /> Chain-of CustodyNumber @7 -f <br /> SECQR Chain-of Custody Record <br /> Field office U1-7 D Additional documents are attached, and are a part of this Rekord <br /> Address 11 +�cJob Name � ✓` <br /> Q,n ch Location <br /> Project# 677,415 1 Task# Analysis Request <br /> Project Manager 2 x <br /> Laboratory En v <br /> Turnaround Time h = N u, cc CO <br /> a °i cNi o m C C <br /> ii <br /> Sampler's Name Q o V 0 0 0 ro 0 =0 y 0 d r O <br /> N V C O I� a W <br /> Sampler's Signature �, '0a °'� a� 'i" 2 0 J rz a aJO <br /> T oN E i Nw ecu 2t Comments/ E <br /> 2 d am d ¢m �<0 2to c° (O am �- a� <br /> Sample [D Date Time Matrix Instructions 1 711 <br /> X --C' <br /> Special Instructions/Comments Relin d b Received b Sample Receipt <br /> Sign Sign Total no of containers <br /> Print Va Print Chain of custody seals <br /> Company SEC Company Recd in good condition/cold <br /> Time C Y 523 Date Time -Z. DateW Conforms to record <br /> Relinquished by "`� Received by Client C40_ ezz ,^ <br />' Sign Sign K, Lx <br /> r Print 4-4�r7 Print f- v V'(4 ' %V1 Client Contact <br /> Company Company K+ A� k(rd <br /> Time_� Date 911 3 `) Time 1 io U U Date C` {�p Client Phone <br /> SECCR CUS7REC Rev 2R9 Q <br /> Date 7 page_� of <br />