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Chain-of-Custody Number <br /> r ,^ SEACQR Chain-of-Custody Record <br /> Field Office AC- tk Additional documents are attached, and are a part of this Record <br /> Address 1-1 2> ,L4 ST r ` <br /> ... •--- Job Name <br /> Location �--c�'k <br /> C� S-t>O p <br /> Protect# fy0 _„••_ � Task# LQC@Z Analysis Request <br /> Protect Manager _Z0FJ I&PWWL r <br /> Laboratory E(L.`1. Com. 0 0D m <br /> Turnaround Time .ti ha b gbzh + cn <br /> m <br /> Samplers Name a� >° EP m -5som v <br /> oo Ua Qo �a rod <br /> Sampler's Signature �-. E vo �N wo ?c~v 20 61im `m <br /> rz <br /> U �o a o a. e o N 6 m N m�.02 p� m U Comments/ E <br /> Sample ID Date Time Matrix z i-co i-m i- ¢co >(0 2 w co'n a(0 �g a P instructions z' <br /> /c� /6;z <br /> Special Instructions/Comments Relinquished b Receive Sample Receipt <br /> Sign,--/ Sig Total no of containers <br /> Print AAP--A_- Print Chain of custody seals <br /> Com any o�"C G i-�u- Compa O a ^�Q Rec'd good condition/cold <br /> TimeDate Tame 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 Data IClient Phone <br /> SLM=GWTKr!M 12M <br /> Date __f I (`�s Page_,_L of�__._ <br />