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MMM I <br /> Chain of <br /> Custody Record Severn Trent Laboratories, Inc. <br /> Client a (0100) nnaL�4 <br /> Daf o Chain of Custody Number <br /> 025637 <br /> ress one Number fArea Code)/Fax Number Lab Number <br /> C) 9VV Page of <br /> r y 1 state Zr ode i1we Conta t La6 Contact Analysis(Attach list if <br /> (MC61-D M I .- I V mores ace is needed <br /> LN <br /> _Pmact Nama I <br /> Lrr�t+o (StateL � `_ ��� CameriYVayb+!!Number � <br /> f\ �,J� Special Instructions/ <br /> Contr-7 <br /> /a hose Ordenqu a No Containers& Condttrons of Receipt <br /> Matrix Preservatives <br /> 1 I Sample I D No and Descnptron ° o o o <br /> (Containers for each sample may be combined on one rine) Date Time w a c N z U m ro <br /> a ¢ y x x x z Nz <br /> IM Z 6 �3� <br /> Vv _ �� M. <br /> i <br /> Possible Hazard identification Sample Disposal <br /> (A fee maybe assessed if samples are retained <br /> Vinq1ted <br /> ❑Flammable ❑ Skin Irritant ❑ Poison 8 ❑ Unknown ❑Retum To Client41..�Posal 8y Lab ❑Archive For Months longer than 3 months) <br /> quired OC Requirements(Specify) <br /> 48 Hours ❑ 7 Days ❑ 14 Days ❑ 21 Days ❑ Other <br /> P17 <br /> Time i Receive d�y " -" Date Time <br /> 121 _ <br /> —i" Date Time 2 eived By Time <br /> 3 Z� Oaf 310 62-t:) <br /> f+ ursheDBy Da Time R carved By ate Time <br /> Comments <br /> DISTRIBUTION WHITE-Stays with the Sample CANARY Returned to Client with Report PINK Field Copy <br /> i <br />