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Chain-of Custody Number: ''' <br /> r _ SECQR Chain-of Custody Record <br /> Meld Office;-._ 5 .� Additional documents are attached, and are a part of this Record. <br /> . � �r��at.��n O ._.__ <br /> Address: 1731V Job Narne: I�i'-- C9l_L '+. Lot k-e+:,r_j <br /> �"8 IG�70o Location: <br /> / s <br /> N1 S y33 <br /> Project 0. Od 1" 0 Task 4 1-04 OA Analysis Request <br /> Project Manager Z i1 A Ve w-e ti <br /> LaboraloryCU <br /> M Q <br /> Turnaround <br /> Hm <br /> e�G� U o <br /> Sampler's Name o o b o �, a m o <br /> Sampler's Signature '� ',E E <br /> U �o ao a e acv � aa` � <br /> Sam le Ito Date Time Matrix z �w E m t- d >� z� (n o0o a �A a� Rj Comments/ z <br /> linstructionsons <br /> - '— ' "•?g Tw <br /> 3l►0 r -K <br /> IA) ;j) yc .Ct <br /> SIi6O,,O Ingtr�,rtinns/C;nmrnents: Relinquished by: Receives{ y: Sample Receipt <br /> Sign Sign Total no.of conlalners: <br /> ++ J Print — - ► w� _ Print _Z_r� r t �� <br /> �� 5 ��M e�,ate + Y ,., Chain of custody seals: <br /> Company �� Company C-x ce 4 c t,.s <br /> /� � Recd.in good condition/cold: <br /> } I'1 r, ,S c, n ►J ti w r TIR18 ro _ Date Tine o o pale <br /> Con <br /> Relinquished by: Receive forms b record: <br /> Sign 11 <br /> Sign Client: 0 <br /> Print �"+�E4O-_ tt� Print ��5 <br /> Srn <br /> Company_._ (C 6,e-^— Company. Client Contact: daaf <br /> Gate <br /> Time <br /> , L me pate i <br /> -- Time G b . <br /> Client Phone: <br /> Dale: l[ i,1 h Page <br /> ot <br />