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IIIIIIIIIIIIj MIFANWSIWIE TMD is >• Ri�end�oodtMI-imm <br /> COWR MM CHAIN OF CUSTO RECORD Page 1 of _ t <br /> Project Name/No I qJp-v-3JSamples Shipment Date ���` _ Bill to.$ <br /> Sample Team Members 2 Lab Destination <br /> a <br /> Profit Center Na 3 Lab Carrtact s IAzj� ` t <br /> Project ManejarTTG+�Lp Gn 01 0 Project Contact/Phone i2 2 Report to. <br /> 0 <br /> Purchase Omer No 6 16 Carrier/Waybill No 13 <br /> 8 <br /> Required Report Date kill:W"s 101111f,411011-1:1 e <br /> n <br /> Sample 14 Sample 15 oete/Time16 Centakw1 7 gunqoe1 a pV,e, 19 Aaguaated Teadn9 20 Condkinn on 21 ompeeal 22 <br /> Number n Collected T Volume aervadw t5nm "Goelpt Aeoard No <br /> n <br /> 7U MILT <br /> r <br /> C <br /> a <br /> n <br /> C <br /> a <br /> c <br /> S <br /> Special Instructions 23 <br /> Possible l-�rd Identification: 24 Sample Disposal: 25 `' <br /> Non-hazard Flammable ❑ Skin Irritant U Poison B U Unknown ❑ Return to[dent❑ Disposal by Lel Archive (mos ) a <br /> r <br /> Turnaro�lnd Time Required. 26 CC Level:27 0 <br /> Normal RushEA I II Itl U Protect Specific (Spec <br /> i <br /> 1 Relinquished by Date: o/ 1. Recenred by 28 ,Jl l Date AA) < i <br /> (SVmu„�/AM1BU-1 �� i Time l St rsV+•W+avur ) -ui7a ` Time. <br /> 2 Relinquished b Date- 2 Received by Date <br /> (aflniarr ,) Time- raWma"IM&iW-1 <br /> Time <br /> 3 Relinquished by Date- 3 Received by Date- <br /> 15"U /Affisetionl Time: IsWmaWAff redo) <br /> Time- <br /> Comments.29 <br /> u�G;3r+51gt <br />