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Chain-of Custody Number: <br /> SECQR Chain-of Custody Record <br /> Additional documents are attached, and are a part of this Record: <br /> Field Office: <br /> Address: ,D } ° �`" ;' ,e Z D Job Name: <br /> Y r+y 0 Og-1 Location: a 07 <br /> Project#,��3 '-6W-QZ Task# <br /> Analysis Request <br /> Project m <br /> Mana er 4 a <br /> Laboratory N a y 8 44Turnaround Ti e - a o x in <br /> 13 9S 7 0 to _ >, <br /> Sampler's Name w a p g i-o h o m o ,� M <br /> Sampler's Signature a ,� `* O m a�o �m n ey <br /> U o m a 2 o o N o m N d o o c m U rr v�� GOmtlleniS� Z <br /> Sample ID Da#e Time Matrix s Co.i-m ¢� >CO. SO CO a SO 0 n a }. `C instructions <br /> f <br /> a <br /> Special Instructions/Comments: Relinquish d by- Received by. Sample Receipt <br /> Sign Sign Total no.of containers: <br /> Print Print Chain of custody seals: <br /> Company Company Recd,in good condition/cold: <br /> Time 0 Date Z' Z ' Time Date Conforms to record: <br /> Relinquished by: Received by: <br /> Sign Sign Client: <br /> Print Print Client Contact: <br /> Company Company <br /> Time Date Time Date Client Phone: <br /> tECOF1CUSTHECRWTW <br /> Date: _2 Page—A—of <br />