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Reference Document N6 <br /> 263 <br /> • <br /> ANALYSIS REST AND <br /> �rr'oup CHAIN OF CUSTODY RECORD* Page 1 of <br /> Project Name/No "45a7ples Shipment Date 7 $ Bill to 5 760 r &-3540,00Z) ' <br /> Sample Team Members 2Lab Destination 8 L +rn04 <br /> Profit Center No a f�,�(� Lab Contact 9 3 <br /> Project Manager4 Project Contact/Phone Q 3�a R`"Report to 10 <br /> Purchase Order No 6 Carrier/Waybill N <br /> Required Report Date # , <br /> Sample 14 Sample 15 Date/rime 16 Contamer1 mple1 fire. 19 Requested Testing 24 Condi wn on 21 l]iaposaj 22 � <br /> Number Des n/T Collected T volume servatnle PrWrairn flampt Record No. <br /> y <br /> two <br /> CL <br /> UJ-� I—HeM <br /> Aw-� I 1eqj 37 <br /> W. <br /> ch <br /> CrCD <br /> Q <br /> Special Instructions 23 <br /> Possibleazard Identification 24 Sample Disposal 25 <br /> Nan-hazard Flammable ❑J Skin Irritant G Polson B CJ Unknown CJ Return to Client[A Disposal by L.ab;�U Archive [rhos ) m <br /> n <br /> Turnaro d Time Required 26 QC level 27 <br /> Norma! Rush ICJ Il❑J III J Pro ect Specific (s ec ) <br /> 1 Relinquished by Date 1 Received by 28 Date 4Vf <br /> (Signawrm/AMmnn) 1�\AAL— <br /> Time (Signau"/Affiliation) Time <br /> Date +�tt' 2 Received b <br /> 2 Relinquished by Y Date <br /> (Signature/Affiliauon) 7422&8 LZ4� Time (signature/Affiliation) Time <br /> 3 Relinquished by Date 3 Received by Date <br /> (sgnaWre/AffiliaGan} Time [slgnawm/Af Jown) Time <br /> Comments 29 / Y &C �i 4 <br /> 1.10 -y— Pfd ?"nTiI <br /> �ir�Ikna�i�S <br />