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Chan-of Custody Number <br /> SECCUR Chain-of Custody Record <br /> Field Office D 1 Additional documents are attached, and are a part of this Record <br /> Address Job Name <br /> Location l <br /> Project#011.q,T ITOn3Task# Analysis Request <br /> _._ <br /> Project Mana er i I <br /> Laboratory o �2 y j <br /> N � <br /> Turnaround Time cl 0N <br /> co = m <br /> iL m <br /> Sampler's Name � F N o <br /> QA0co <br /> Sampler's Signature �,� a �- <br /> U a o 0..o a. �o o� R o m w o o v °' U Comments/ 3 <br /> Sam I ID Date Time Matrix x i-co w a`C r i co cn( a te a r Q Instructions z <br /> Z R_M D D I Q5 3 X `S` µ L 1 k <br /> E � <br /> Special Instructions/Comments Relinquished by Receive Sample Recei t <br /> Sign I Sign Total no of containers <br /> Print Print Chain of custody seals <br /> Company a + Company_ Recd in good condition/cold <br /> r Time 7-_ Date Time ' Date Conforms to record <br /> Relinquished by Received by Client 56CC) iZ_ <br /> ��a y Sign Sign+ <br /> Print Print Client Contact 1 �� <br /> Company _ Company <br /> Time Date Time Date Client Phone <br /> SECAR CUSTREC Rev 299 <br /> Date L o—O Page Z of <br />