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i "�r 1, i � �r.�.� � - <br /> a ll i ! 1 1 1 +n l I l 1�1{ <br /> INTERNATIONALTELOGANALYSIS REQUEST AND Reference Document No. `73 572 <br /> CORPORATION c CHAIN OF CUSTODY RECORD* Page 1 of _J_ <br /> Project Name/No. <br /> Jm <br /> les Shi ment Date 7 3 !�? 5 <br /> P P BIII to.-_'�._ <br /> Sample Team Members 2 s:+t r Lab Destination e VA• 5 le <br /> Profit Center No. a -� f� Lab Contact, — � i <br /> Project Manages �� �►� (rte �r Project Contact/Phone 12�_ 6:g, Is P° 3 Z 710c' I ' <br /> Report to:1 fl ']J� . ..�'[ ��,_ <br /> Purchase Order No. 5 $ Carrier/Waybill No. 13 <br /> Required Report Date <br /> Sample 14 Sample 15 Date/Time 16 Container'7 Sample 1 E 7779 <br /> Requested Testing 20 Condition on 21 Disposal 22 <br /> Number Descri 'on/T a Collected T e Volume sarPro ram Recei t Record NMR-000, 5�O1L 1Scow � oa � � WI1-�E� is� i <br /> 5SA M 00ry <br /> Af <br /> 7 <br /> M4- � AptS 1 _ago <br /> �� 6 f l_ Ia k G T- <br /> t <br /> r <br /> r <br /> C <br /> ....,,�.o__ .,._- � { <br /> iii Instf uCtlanS: 23 <br /> Passible Hazard Identification: 24 Sample Disposal: 25 <br /> Non-hazard IJ Flammable IJ Skin Irritant IJ Poison B I„J Unknown Return to Client[J Disposal by Lab[Ir Archive_ (mos.) <br /> Turnaround Time Required: 26 CC Level: 27 <br /> Normal �J Rush[J] 1.1J I1.1-i Ill. Project Specific (specify): <br /> G <br /> 1. Relinquished by 28 ate: . 1. Received by 28 Date:— t <br /> (Signature/Affiliation) TTY04iime: 0 D f9gnature/Affiliation) C <br /> Time: <br /> 2. Relinquished by Date: 2. Received by Date: <br /> (Signature/Affiliation) <br /> Time: (Signature/Affiliation) Time: <br /> 3. Relinquished by Date: 3. Received by i C7- _ <br /> (Signature/Affiliation) Time: (Signature/Affiliedun r C' w Date: <br /> �/-'QC> <br /> Comments:29 � <br /> 3(7A4 <br />