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04TERNATIONAL ANALYSIS REQUEST AND Reference Document No <br /> coWOuAno rr CHAIN OF CUSTODY RECORD* Page 1 of I <br /> ' <br /> Project Name/No. 1 D37• !r4 <br /> Samples Shipment Date 7 11/y 6D Bill to.5 <br /> ample Team Members 2 Lab Destination a o t&� T o <br /> Profit Center Na. 3 �/ Lab Contact 9n� _ <br /> Pro a dun W4 o T Project Contact/Phone 12 2 T 10 <br /> sect Manager_{ <br /> p,� Report to. —_'�RMe-21's -�- <br /> Purchase Order No _9� �21�_ Carrier/Waybill No 13 _—N <br /> Required Report Date 11 _— <br /> +A <br /> Sample 14 Sample 15 pab/4ima 16 ,1 mp�1 py,e, 19 Requested Teathm 20 Conft on an 21 049pMml 22 <br /> Number Collected Valuma Receipt Record No. <br /> o � L - 010055-0 <br /> r U0 LT—b� a <br /> 0 <br /> 11rr. Ifni 11V�r saw am Iftff NNE W � <br /> ' <br /> M <br /> Crm <br /> C7 <br /> Special Instructions: 23 <br /> Possible and Identification: 24Sample Disposal. 25 <br /> No"EtzardXJ, Flammable ❑ Skin htant ❑ Poison 8 ❑ unknown ❑ Return to client 13 Disposal by Labb Archnm (mos I M <br /> Turnaro nd Time Required: N QC Level:27 <br /> Norma Rush A III❑ Pro act ci ). <br /> 1 Relinquished 2 r Data u 1 Received by 28 Date <br /> [S�pneu+e� i .—.:� <br /> Time: Time o <br /> 2. Relinquished by Date: 2 Received by Date <br /> is nelUL.a/Alffistan) Time. i "/AffKsd li Time <br /> 3. Relinquished by Date: 3 Received Date _ <br /> 1SWah"IArr"m) Time: [: moi Time <br /> Comments.29 <br /> A 371591 <br /> r r � I� � I� � � r � � � e■� � e■Ile r ro I� <br />