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1 <br /> N <br /> Chain of 1 L <br /> Custody Record Severn Tre ahoratories, Inc. <br /> client Project Manager 24 tos0ll <br /> ClienDate Chain of Custodv Number <br /> tPIM MA t �Z-, -128441 <br /> Address Telephone Nu ber(Area Code)/Fax Number d Lab Number t t <br /> ZS ZS- /V�M3 Fe, A s'vrsE �YSo ' CAI 6 - 2.`� -- s 7 P Page 1 of / <br /> Ci State p-Code Site Contact Lab Contact Analysis(Attach list if <br /> CA- Q 3 5 �3 p�,-y mores ce is needed <br /> Project Name and Location(State) CarnerAVaybill Number <br /> F"6 r-Avyt-6/ 6Avn-1!5" O65 •QL' �o -'1976 Special Instructions/ <br /> contract/Purchase order/Quote No. Containers& f` Conditions of Receipt <br /> Matrix Preservatives �0 <br /> Sample LD.No.and Description Date Timeti y ep <br /> (Containers for each sample may be combined on one line) <br /> 59- 10- 11 <br /> ViJ <br /> �, 5 r 8 3i off o.30 ✓ <br /> (YED IN GOOD COND1110H <br /> f?r o ✓ WvaEH roc <br /> s _ 2 2004 <br /> w <br /> IN1. <br /> 0 <br /> o - <br /> P 1,9.Hazard Identification Sample Disposal <br /> ,N.JJ (R fee maybe assessed if samples are retained <br /> Non-Hazard ❑Flammable 0 Skin Irritant ❑Poison B ❑Unknown ❑Return To ClientDisposal By Lab ❑Archive For _Months longer than 1 month) <br /> Turn Around Time Required {1 QC Requirements(Specify) <br /> ❑24 Hours ❑ 48 Hours ❑.7 Days 14 Days ❑21 Days ❑Other <br /> 1.Relinquished By r/¢ C Dat. Time 1. B Date Time <br /> 2.Relinquishedy Dat Time 2.Receive By Date Time <br /> �t/z Y <br /> 3.Relinquished By Dare Time 3.Received By Date I Time <br /> CommentsCvso <br /> G 1 �` t)✓1��l 5J 1ti(' �( TD yftic /itlGt7rG !O�� <br /> 5�•� >c � s EQi�I,J � <br /> 1,.)e-re-1,.)e-re- %✓� � <br /> wDlSTRIBUTION: WHITE•Returned to Client with Report; CANARY-Stays with the Sample: PINK•Field Copy o✓! 2 /�OK�!�� ZGO�, <br /> rd��G� AJC, <br />