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Q0 � �G <br /> CHAIN OF CUSTODY No. 2 Page of. <br /> CONSULTANT'S NAM A } ADDRESS ( � �� W �IT� STp�E ZIP CODE " <br /> BP SITE NUMBER 1 BP C RNER ADDR_7SYCITV CONSULTANT PROJECT NUMBS <br /> lo-o97 _ �a- <br /> E—ONSUCTANT PROJpj MANA RPHONE NUMB R FAX NUM ER CONSULTANT CONTRAGT NUMBER <br /> OW�,,) <br /> �1� ��fir)15 a 9 -)�Sa�3 <br /> BP CONTACTBP ADDRE PHONE NUMBER FAX NO. <br /> _1�& 1� tq <br /> LAB CONTACT LABORATO ADDRESS PH U� FAX NO <br /> �s t01 t)o '� FS -a X73 <br /> SAMPLEOPY(Please Print Nam SAMPLED ( nature) SHIPMENT DATE SHIPMENT METHOD <br /> E \ X11 <br /> AIRBILL NUMBER <br /> TAT: 24 Hours 48 Hours 1 Wee Standard 2 Weeks ANALYSIS REQUIRED <br /> I <br /> COLLECTION CONTAINERS P9ESERVATIVE d <br /> SAMPLE DESCRIPTION DATE SOIMATRIX MATRIX <br /> TYPE LAB COMMENTS <br /> COLLECTION NO. (VOL.) SAMPLE# � <br /> TIME <br /> z 0% <br /> C - f, 6 � <br /> W zz Q2 <br /> W ~ <br /> AA <br /> W 879 <br /> vJ <br /> `3JA <br /> $ 'D <br /> ADDITIONAL COMMENTS <br /> RELINQUISHED BY/AFFILI TION DATE TIME ACCEPTED BY/AFFILIATION DATE TIME <br /> 12=3d <br /> CLV-16722 Distribution: White-Original(with Data) Pink-Lab <br /> Yellow-BP Blue-Consultant Field Staff <br />