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wtali!!► <br /> 1111111111111w nor �' � � :'T'1 �"" 5 � �5 '`'n � ,n't'7 Ar,77 ,�0-Trzrz , �ATFONAL ANALYSIS REGGICST AND Reference Document No u 3 0 b U c? <br /> LiA TEChROLOGY <br /> cORPORAMN CHAIN OF CUSTODY RECORD* Page 1 of ! <br /> r � <br /> Project Name/No 1 ��� Samples Shipment Date �o�n x b Bill to 5 �(3 r� (�til0 <br /> Sample Team Members 2 �-�. Lab Destination $ <br /> Profit Center No 3 5 1 O Lab Contacts _ <br /> Project Manager4A.��`n�� t ��� Project Contact/Phone 12 i NWt t tv.S Report to 10 <br /> Purchase Order No 6 VJ `' Carrier/Waybill No 13 <br /> Required Report Date 1 Q <br /> "Container <br /> a . a <br /> Sample 14 Sample 15 Date�me 16 lel p� 19 20 21 22P PP Requested Testing Condiltion on Di!sposallNumber Descri tion/T a Collected me servatnfe P ram Receipt record No <br /> o a �. Q- 0 4 �.r 1 `t 0 n' A c O( 61759 a <br /> x xt In Ut �� P i 3e1 11 T <br /> n V\ t, i- ki 0 w�b�l o f �3 6 7iLt 6© n <br /> , , <br /> o �: �.� <br /> 61761 <br /> 3 <br /> PA 1100L�"�b �K t-t' �� "ITPN ���PA � ��P,OIL I 61762 <br /> xlzz 1 �( L-T Lf Tp D1 S9 I <br /> q b rv� � ,� Dr Y fi t 763 <br /> CD <br /> M;.s i$ 3 <br /> Cr <br /> \ F <br /> 0 <br /> 0 <br /> Special Instructions 23 <br /> Possible Hazard Identification 24Sample Disposal 25 <br /> Non-hazard J Flammable J Skin Irritant J Pui--n B „J Unknown J Return to Client J Disposal by Lab J Archl�e [mos ) <br /> Turnaround Time Required 26 GC Level 27 <br /> Normal `J Rush J I II J III ProecSpecific [s eCi ) En <br /> a <br /> 1 Relinquished by 2D =Q Date 1 Received by 28 ',gL Date oZ-,Z�Z-�� <br /> [Signature/Affiliation] Time w (Signature/Affiliation) Time 161 <br /> _5 <br /> 2 Relinquished by Date <br /> [Signawre/Affiliation] 2 Received by Date <br /> Time [Signature/Affll:ation] Time <br /> 3 Relinquished by Date 3 Received by Date <br /> [Signature/Affiliation] Time (Signature/Affiliation) <br /> Time <br /> Zomments 29 <br /> MCA 3 15,91 <br />