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Cham-of Custody Number <br /> r, <br /> r - SECQR Chain-of Custody Record <br /> %Additional documents are attached, and are a part of this Record <br /> Field Office <br /> ;r Address �'�w/�!O✓JfHO�-i���i � �f Job Name <br /> Location <br /> eA <br /> Project# `� Task# Analysis Request <br /> Protect Manager A <br /> Laboratory Y N <br /> Turnaround Time � o <br /> / m =° o IN 'a °g oma. <br /> - a - r :: m o <br /> Sam lees Name d w m 0 0 0 c o `—°n y 0 ca `r' 5 <br /> Sampler's Signature o �, �, p �« goo <br /> '" a E <br /> U o a o d a s o c`v va o 0)to t5;6OJ W o o v as U p Comments/ <br /> Sample ID Date Time Matrix z ��rr c r Co. r a O (a T6 W U)0 a W r n a r �-. U Instructions <br /> 12 I-zYLr6 I 1:oo <br /> g` � 3 �•rs•� 1a;:o <br /> 5 <br /> W,- 126. 6 ',g0 l3 <br /> Special Instructions/Comments Relmquis d b Received by Sample Receipt <br /> Sig Sign _ Total no of containers <br /> (JS 7 �� Print `fri Prin# Cham of custody seals <br /> Company S �`r 9A Co p y Recd in good condition/cold <br /> Time ` S Date ime D Conforms to record <br /> Relinquished by Received by -} - <br /> Sign s Sign M t Client <br /> Print Print r rte``' Client Contact <br /> Company Company r� ° t, 2 <br /> Time Date Time Date ` 26 14,Client Phone <br /> SECOR CUSTREC Rav 1N5 <br /> Date 12& Page-2L-of <br />