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i <br /> Cham-of Custody Number <br /> SECOR Chain-of Custody Record e, 3 2I <br /> Field Office Q Additional documents are attached, and are a part of this Record <br /> Address .2 v .ni mit icc Job Name <br /> Location U f/ LJ X -- - <br /> 1-1162 c�-- <br /> Project#07 3 7 0 `&# Analysis Request <br /> Project Manager s <br /> Laboratory ° _ c <br /> Turnaround Time S7f1rIDl1 P, N a - C <br /> CL CO do M m E c C <br /> m 0 96m C ' OU I O <br /> N C <br /> LU <br /> dY > <br /> Sampler's Name �e/lser o 00 F5 V L o °o )0 i w r� � <br /> Sampler's Signature o C)L; 'V LO m �� ff `� � I _ a <br /> U do ao CE °n o� �a Anil do -awl °' U C011iments/ <br /> Sample ID Date Time Matrix z �- a >rD . o. a ;-� a �- Instructions z <br /> 3 0101 <br /> E <br /> i <br /> k 1 <br /> E <br /> Special Instructions/Comments Relmd Received by Sample Receipt <br /> Sig r Sign_ Total no of containers <br /> Print "9T ut Print Chain of custody seals <br /> I <br /> Company - ` , _ Company I Recd in good condition/cold <br /> Time U �- Date �� Time Date Conforms to record <br /> Relinquished by _ Received by Client — <br /> Sign Sign .---�,� <br /> Print _ _ _ Print Client Contact <br /> Company _ Company EX <br /> Client Poke 31CV <br /> Time Date Timea E_. k � Dated/14100 <br /> SECOA Pi35TREC Rev 2M 2 <br /> Date J I �� I � Page ( of <br />