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rs/1�� MAY •'7 i�MY�Y� li��Y • �•var•w.r vvvra.•.v w . �... <br /> COTECHNRPORATION CHAIN OF CUSTODY RECORD" Page 1 of <br /> Project Name/No 1 4916' 031, 1# _ Samples Shipment Data 7. . — <br /> -12 1I 3 BIII to:5 oqr <br /> yr <br /> Sample Team Members x r _ Lab Destinations S e9 Ibl r4 a <br /> n <br /> Profit Center No 3 S Lab Contact L-5% `� a <br /> Protect Manager— -�d 7�/Qen �it)R�_.4 Project Contac t/Phone �� °�� 5 , 3 3�7 �o ��1 V <br /> Purchase Order No O 13 Report to: <br /> 'o <br /> 391►9 Carrier/Waybill No .A <br /> m <br /> Required Report Data 11 --- 11 ki 149 • � � <br /> Sample 14 Sample 15 Rate/Tir" Contsinsrl Sa�nPl�i Pro. 19 Requested Tend" � Condition on 21 C]ieposel 22 <br /> Number Celreated Valwpa ssrvrdm ram Ascord No. <br /> FFL raEms �aa <br /> itU toy <br /> or <br /> x <br /> Special Instructions: 23 <br /> Possible H and Identification: 24 Semple Disposal. 25 <br /> Non-hazard Flammable ❑ Skin Ment ❑ Polson 0 ❑ Llnknowri ❑ Return to tent❑ Disposal by Lab Archive (mos.} <br /> Turnarnd Time Required: 26 0 Carrel:27 <br /> Normal Rush ! Q,1J III❑ Pro ect cific s 5 <br /> 1 Relinquished by2 Data. 1. Received Date <br /> I +rot l �& ime: JW a—/ 1 Time- <br /> 2 Relinquished by U Date: 2. Received by Date. <br /> i l l Time: WVmb ro/Affik"l Time- <br /> 3 Relinquished by Data: 3. Received by Date• <br /> I9VW—/AffA@tWn1 Time: Time: <br /> Comments:29 <br /> MCA WIWI <br />