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N Chain of T L <br /> ICustody Record Severn Tre aboratories, Inc. <br /> STL-4124 (0901) <br /> Client Project Manager Date Chain of Custodv Number <br /> Address Telephone Nu ber(Area Code)/Fax Number O Lab Number <br /> ZS Z� BMs Pe, P 3'v—'r63,5-0 cl1 t/O Z 1 - 3 7 P Page of <br /> City State Zip Code Site Contact tab Contact Analysis(Attach list if <br /> GA- Cr $3 5 GY36A r rlL mores 7ace is needed <br /> Project Name and Location(State) Carrier/Waybil!Number <br /> FA-PC FAV)-l-Cl* CA,-n,/,7Y 6 c ,Q pogo Z� 9 7 a o Special Instructions/ <br /> Contract/Purchase Order/Quote No. Containers& N Conditions of Receipt <br /> Matrix Preservatives 4p <br /> Sample/.0, No.and Description Daterme � y � 6 � <br /> Ag 0 <br /> (Cntainers for each sample may be combined on one line) x x i 1,1;2� <br /> 59- 1 e i I ---d0 31 n y <br /> ✓,3-I LO 19.5 <br /> y — f 8 31 a,' 0"30 ✓ F FECEIVEDINGOOoCONDIGN <br /> 3 ✓ wvaEk coc <br /> 0 <br /> 0 <br /> 0 <br /> Pos 'le Hazard Identification p <br /> Sample Dis osaf / � �.ta , <br /> � L�'1,d/ b,ed if samples are retained <br /> NJ Non-Hazard ❑Flammable ❑Skin Irritant ❑ Poison 8 ❑Unknown ❑Refurn To Client Olsposal By Lab ❑Archive For <br /> Tum Around Time Required QC Requirements(Specify) <br /> ❑24 Hours ❑48 Hours 0.7 Days 14 Days ❑21 Days ❑Oth ar <br /> 1,Relinquished By Dat •7 Time Date Time <br /> 2.Relinquished y Oat j 7 Time` Z Receive 8y Date Time <br /> 3.Relinquished By Date Time 3.Received By Date Time <br /> Comments <br /> A <br /> 0 <br /> wD1srRIBuRow WHITE-Returned to Client with Report: CANARY•Stays with the Sample; PINK-Field Copy <br /> w <br />