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ANALYSIS RE ST AND Reference Document NCS 2 g <br /> i°IAIN ®F CUSTODY RECORD* Page 1 of <br /> 1 1763 7 <br /> Project Name/No 1�� _ Samples Shipment Date __!�� � Bill to off � � ��p�_ _ <br /> Sample Team Members 2 _ } _ Lab Destination <br /> Profit Center No - Lab Contacts[4�_ __ _ o <br /> Project Manager j _6 Project Contact/Phone (qZ5-1?--�B-"�--6J-(?0Report106 � � to — ___ _-- _ <br /> Purchase Order No _ _ Carder/Waybill No <br /> m <br /> Required Report Date 11_ - - A <br /> • • ■7Aequested <br /> nSample 14 Sample 15 oate�ms16 Container1 SamplePre• 1Testing 20 Condlition on 21 Disposal 22 <br /> Number Descri tion/T a Collected T e Volume servatFvoram Receipt Record No <br /> CD <br /> -� <br /> a <br /> 1 o <br /> _ 4 <br /> - ` In <br /> _ m <br /> M <br /> n <br /> 0 <br /> -„ <br /> 0 <br /> Special Instructions 23 3 <br /> Possible kja rd Identification 24 Sample D(s osal 2s <br /> Non-hazardX Flammable IJ Skin Irritant Polson B Unknown 12 Return to Chen Disposal by Lab Archive_ _ (mos ) <br /> Turnaro Tlme equlred 26 QC Level 27 <br /> Norma Rush❑ 11-A II U III I_j Project Specific [s ac 1. 5 <br /> 1 Rel quished by Date _-! 1 Received by 28 Date _ - C <br /> (Signature/Affiliation] Time / (Signature/Affiltataon) Tlme a <br /> 0 <br /> 2 Relinquished by Date _ __� 2 Received byr Date <br /> (9gnature/Affiliation) /SA <br /> Time (Signature/Affiha -o i � �� Time �2 <br /> 3 Relinquished by Date _ _ 3 Received by Date <br /> (Signature/Affiliation) Time _ (99nature/Affihadan) Time <br /> Comments 29 <br /> rWc, , <br />