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® INMNNATIO AL ANALYSIS REQUEST AND Reference Document No. 3 -113 5 71 <br /> CORPORATION (F A L HAIN OF CUSTODY RECORD* Page 1 of � <br /> Project Name/No. 1 PAC I- _� am les Shipment Date ? 2 i_ O 5 <br /> ---✓ P P 1 Bill to:__-_ <br /> Sample Team Members 2 90Sm ;" Lab Destination 8 OA-Si <br /> Profit Center No. 3 T T A49 <br /> Lab Contact_-../�jI, t �o Jrf-, S.1 ( S r <br /> Project Manager4 � ��" �,_e d <br /> S Project Contact/Phone 12 ACsecJS 5lU 372g10D c <br /> 10 <br /> Report to: <br /> Purchase Order No. s bS `{� Carrier/Waybill No. 13 _ <br /> Required Report Date 11 Z -�I r, _ o <br /> u <br /> Sample 14 Sample 15 Date/rime15 Container Sample 16 pre- 17Ru)esto <br /> d Testing 20 Condition on 21 Disposal 22 <br /> Number Descri ion j Collected Type Volume serve 0. ram Recei t55A- E Mk-00 ! r]'�I Lr t c it.l r Sz96 123 c erVe yl1 &i, AOnaara- tr se I, K <br /> SS►9- � �1R- oo z (Z3Ar <br /> n <br /> b03 <br /> . J� ,t", C <br /> Dv 12 <br /> �,.� firms 4)< y 4sJ T° ,rss Tek <br /> STP r►M�-�1 134 J V, IC6a ?'DTA L. Pb l,t_T_ <br /> 0 <br /> , c <br /> Special Instructions: 23 `- <br /> Possible Hazard Identification: 24 Sample Disposal: 25 <br /> Non-hazard IJ Flammable !„� Skin Irritant !J Poison 8 LJ Unknown Return to Client I-- u <br /> J Disposal by Loh Archive (mos.) <br /> Turnar and Time Required: 26 DC Level: 27 <br /> Normal 4— Rush[J L!J IlJJ IIIJJ Project Specific (s eci ); _ <br /> 1. Relinquished b 28 � Date: �"„-_ 1. Received by 28 Date: <br /> T <br /> (Signature/Affiliation) I Time: �{ (Signature/Affiliation) �— -- r <br /> Time: <br /> 2. Relinquished by Date: 2. Received by Date:_ _ <br /> {Signature/Affiliation) Time; (Signature/Affiliation) Time: <br /> 3. Relinquished by Date: 3. Received byDate:_ <br /> (Signature/Affiliation) Time: (Signature/Affiliation) Time: <br /> !�/ <br /> Comments:29 <br />