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r✓1vtVV `1J <br /> Cham-of Custod <br /> 1u 7� SECQR Chain-of Custody Record <br /> Field Office 07 7 U Additional documents are attached, and are a part of this Record <br /> Address 50/ <br /> 7 L. 'w/do Job Name - 01` /Ib <br /> O Location 000 fIST` l SS <br /> Project #077.#/7_37,DO 3 Task # Analysis Request <br /> Project Mana er 7 DD Ermhj <br /> Laboratory CC-EL #W <br /> Turnaround Time_ 5z& � q N a �" k C <br /> a <br /> 212 K <br /> 04 T o U' $i C7 a 6 0V <br /> Sampler's Name u P� o�fz LU R�- <br /> r� O �yD �O -;5 b0 .0O dr N <br /> Sampler's Signature C a W �'W ° .� 2 <br /> U d 0 d 0 d 0 0 O N O N N d 0 O v N U Comments/ <br /> Sample ID Date Time Matrix T r 90 r W r 0 1 _(n u,m a SO r a 2 r Instructions z <br /> 11 A 1110 tooK X W01Q, 2,4 <br /> 7 Rip &A -\ I �— W tUI21a5 3 <br /> Mw _ 1 E 0(ol210V <br /> W -Z <br /> W �5fi$ WDI012(a <br /> W <br /> VV - X205 i 27 <br /> W(QJ7_72 <br /> MV\J '9 0101213 Ilk <br /> Special Instructions/Comments Relinqhe b Receive y Sample Receipt <br /> Sign ' Sign . Total no of containers <br /> Print ' <br /> op "z Print Chain of custody seals <br /> Company Company Rec'd in good condition/cold <br /> Time 10'.1.3 Date Oflt.2101 Time to, Y3 Date oz/-/ o <br /> Conforms to record <br /> Relinquished by Received by Client ShC��z <br /> Sign Sign <br /> Print Print Client Contact W� <br /> Company Company Client Phone .q t b <br /> Time Date Time Date <br /> SECOR FUSTREC Rev 2199 <br /> Date I f / 0 r Page of <br />