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rEc �YAi# d Heteren Document <br /> co RATION CHAIN OF I �� <br /> �aods CUSTODY RECORD Page 1 of � <br /> Protect Name/No _1 _`T�37$$ Samples Shipment Date eqx qC� sal to 5 r <br /> i <br /> sample Team Members 2_ '� Lab Destination e �C L ��� 1 �- $ O,G�Ju_p BVo�_� <br /> I <br /> Profit Center No 3 374SI-Lo— -- Lab Contacts <br /> Protect Manager4d 12id 'Ir 0 GeZS Project Contact/Phone h <br /> Purchase Order No s_�I1� tk!k� Cairier/Waybill No 13_ Report to 10 CQ Y <br /> _ [,.,a~y�,.v\,S ��.0►0..3 � <br /> Required Report DateSample 14 1 <br /> NumberDescription/Type <br /> Sample 15 Date�me 16 Contameri Sample 1 Pre- 19 Requested Testing 2U 21 � <br /> Descri tion/T a Collected t e Volume sarvativs Condition on Disposal 22 <br /> Pro rem Re t Record No. <br /> `� ].], p1 So 1 [-; �,r 1k 1 L S}ie�JQ�1 ti a <br /> A M <br /> t1-j0� 1 1..� t�� o o r <br /> � y .Lill ep�,Av <br /> 0 `� W�. S�LL�°tb I +��� lk ut LJ'�0SQI go1 � t�od <br /> o 811.1-19 1 Q; x L <br /> D1 yvsk,� X015 tv�o f� <br /> W 1 '�S 1 L.� �r LK���1DwvilX,1 8015mo 66 711 <br /> c b <br /> r� � <br /> Special Instructions 23 7'12 <br /> Possible Hazard Identification 24 Sample Disposal 25 E <br /> Non-hazard IJ Flammable IJ Skin irritant IrJ Poison B 1.) Unknown I Ey <br /> Return to Client Disposal by Lab I� ArchiveEn <br /> Turner and Time Required 26 QC Level 27 ("1Q5 n <br /> Normal Rush'„ n <br /> I I II I J Ili J Pro ect Specific (5 ecr )____ <br /> 1 Relinquished b 28 Date �.Z, 1 Received by 28 <br /> (Signature/A�habonJ _ <br /> - Date <br /> Time !(p C <br /> 15ignetura/A�haGon] ` r C <br /> 2 Relinquished by Dated �� Time /5` a7 9 <br /> rsIg <br /> 2 Received by d <br /> ^atone/ArrhacronJ Date <br /> Time IS<gnntimr/Afhh�tinn] <br /> 3 Relinquished byTime <br /> 4tu <br /> ignare/Afl Date W] ^�^ 31 Received by <br /> till Date <br /> g'nature/Affihatron] <br /> Comments 2s ' 4 ,.... Time <br /> r a,)GOXDMO JNOIPN�X <br /> i��1if}SPACEABSEN�„� <br />