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i <br /> r rr rr r rr �r �r r r rr� <br /> Chain of } <br /> Custody Record Severn Trent Laboratories, EPc <br /> STL-4124 (0700) Date Chain of Custody Number <br /> Client -0 V Prot t M ger f r � ��`�, <br /> Ff1 002561- 8 <br /> lephone Nu ber(Area Code)lFaz Number Lab Number <br /> C ZS i� Page of <br /> City 5ate Zip Code SNecontact Lab Contact Analysts(Attach list if <br /> a mores ace is needed <br /> Pr�Name and ocati n{5tate) Carner/Waybill Number <br /> Special Instructions/ <br /> ontract/Purchase OrderlQuote o Containers& Conditions of Receipt <br /> -N I G L WOO Matnx Preservatives t <br /> Sample!D No and DescriptionV <br /> Date Time o q z° <br /> (Containers for each sample may be combined on one line) a r y <br /> — I <br /> Possible Haza fdentrficalron Sample Disposal (A fee may be assessed if samples are retained <br /> on Hazard ❑ Flammabfe ❑ Skirt Irritant ❑ Poison B ❑ Unknown ❑ eturn TO Client Disposal By Lab ❑ Archive For Months longer than 3 months) _ <br /> Tum Around Time equired OC Requirements(Specify) <br /> ❑ 24 Hours 48 Hours ❑ 7 Days ❑ 14 Days ❑ 21 Days ❑ Other <br /> 1 Received By Date Time <br /> I Relinquished Date Time y�� <br /> l r <br /> Date Time 2 eived By ate, Time <br /> 2 Relinquished By � <br /> _ to rme 3 Received By Date Time <br /> 3 nqurshed By C <br /> C '64 ertG - L 371 U11-- ,� 7 J r i 0 I (�7f t.�l J 3.0 �t-� <br /> DISTRIBUTION WHITE Stays eSampI4 CANARY Returned to Client with Report PINK Field Copy <br />