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I <br /> Chain-of Custody Number d <br /> Wt 1240& SECQR Chain-of Custody Record <br /> � j <br /> Field Office 7- Additional documents are attached, and are a part of this Record <br /> Address :ZDJ`7l �.or� 4 Job Name <br /> �7�•►�ir�ra ��r�© a• ��7Q Location d u n, 'Sr5 ! <br /> I <br /> Project#D77 X117-3 # Analysis Request <br /> Project Manager oar l a �— <br /> Laboratory CD <br /> Turnaround Time -S O N _ m-8 m <br /> =_ ` <br /> aCUU j OV U <br /> m" <br /> c o <br /> 2 r p ro� a O. 5 m U <br /> Sampler's Name,— v a v @ m` a o ch Z <br /> m E E 00 00 cn aQ �° a`�r av W d <br /> Samplers Signatt i <br /> = E o °4 U <br /> Commensa. Mddo r ` <br /> sample 1D Date Time Matnx aoo <br /> Instructions Z <br /> .�, ) ,. J 411013-10 <br /> Special Instructions/Comments Relinquis by Received by Sample Receipt <br /> Sig Sign Total no of containers J <br /> Print Print Chain of custody seals <br /> Company Company Rec'd in good condition/cold <br /> Time 7. 4u'l pate ri � Time Date Conforms to record <br /> Relinquished by Rece�ve�b Client _,S <br /> Sign Sign <br /> Print Print Client Contact <br /> Company Company <br /> Time Date Time Oq Date Client Phone g6l <br /> SECOR GUS REC Rev 2199 <br /> Date Z� I? lam/ Page of,)— <br />