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AA L U A 1� �ferlfte @Wrnr� N 3l� <br /> Page1 of <br /> the <br /> �igr0f;P ,� �` , CHAIN OF CUSTODY RECORD* <br /> Project Name/No 1 �!� Samples Shipment Date 7 Bill to MT C6/ <br /> PG/� v w o <br /> ')ample Team MemPers '�`?d`S" b Destination $ �M �_ ,����,P, c 0 <br /> b ,{��o� Lab Contact 9 0 <br /> P O <br /> Protect Manager4 s �6 GATIIP Project Contact/Phone 2 Z5 zS8 05 Report to 1° <br /> Purchase Order Na 6 Carrier/Waybill No 13 m <br /> c�` l? - 3 <br /> Required Report Date 1 + - - n <br /> • • <br /> Sample 14 Sample 15 Date�me16 Contamerl Sampler Pro. 19 Requested Testing 20 Conditwn on 21 Disposal 22 <br /> n/T Collected Volume servawe ram ReceiptRecord No <br /> Number Des E , Tall-3 coca o rr' m <br /> I Sam <br /> 5T ��' <br /> I1risF 0fPF - 1� TAM-4 <br /> m <br /> 1 , nclf <br /> Q <br /> f <br /> a <br /> n 9 M F(Z rn q W C <br /> - <br /> - G26riPwOc- rub Is3U 3,c4oM x <br /> 0 <br /> 0 <br /> 3 <br /> Special Instructions 23 <br /> Sample Disposal 25 <br /> Possible Hazard Identification 24 Return to Client EJ Disposal by Lab LJ Archive (mos ) <br /> Skin Irritant (A Poison B J Unknown <br /> Non fisZard �J Flammable g 27 <br /> Turnaround Time Required 26 1 Le lel lli [J Project Specific (s ec ) <br /> Normal Rush J Date �//:ad �0r <br /> Date i//2/6" _ 1 Rece+ved by 28 Time V '4 0 <br /> 1 Relinquished by 28� /J Time p��o I iafrmum) s <br /> cS9wwm/Aff ,l -£yived by Date E' <br /> r� Date _tea �e r Time <br /> 2 RBI4f1glS15tlec� by Time 13 k S <br /> tr��, �,gf�irredo►11 - - .f 14 Q� r.0 • Date <br /> D� / - -c:+� 3 Received by Time <br /> 3 Relinquished by e Time <br /> ( p1re/,gffi6auon} <br /> Comments 29 <br /> MCA 3115191 <br />