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1 t <br /> 4 A�lu LY RaE�-I AN �� Heference ocument 7 <br /> , 'INOLOGY <br /> d6CORPORATION CHAIN OF.CUSTODY,RECORD Page 1 of <br /> 1 �-� '�- �, 0 7 f 9 5 <br /> Project Name/No. 3 --3 - — Samples Shipment Date 7 2-1 L_"------_-- Bill to: ._..-.� <br /> Sample Team Members ?_.-� - �5.-- _ Lab Destination F?<< P8€4 _ S - + gyp ver o <br /> Profit Center No. 3.3 S y s z- 1 Lab Contact s -_H _.T _J �f_t" J-� 3 - - o <br /> - - - - - <br /> Project Manager a C• _�'� �S I / <br /> _— Project Contact Phone 12LFad,stS�3 <br /> Report to:1 �' �� - --- <br /> Purchase Order No. Carrier/Waybill No. 13 'DQ-,,e_-- <br /> Required Report Date 113�s�` �',T ,,---��— 1 rqS <br /> CD <br /> CA <br /> Sample 14 Sample 15 Date/Time 16 Contained Sample Pre- 1 Requested Testing"20 Condition an 21 Disposal 22 <br /> Number Descri tion/T a Collected T e Volume servative Program Rec iat Record No. <br /> i m <br /> 2gs�` �L R' l N� TPHeA1106 61943 <br /> 61944 <br /> k $ <br /> ., <br /> i::J�u1ilil�it]JPFiOPRIATE _ ... co <br /> CD0- <br /> ' n <br /> 0 <br /> Special Instructions: 23 L, o <br /> Possible Hazard Identification: 24 Sample Disposal: 25 Ln <br /> Non hazard Flammable „J Skin Irritant �,J Poison B �J unknown, Return to Client ,J Disposal by Lat�✓,� Archive_._ (MOS.) m <br /> n <br /> Turnarou d Time Required: 25 QC Level:27 <br /> 1. Relinquished h J 5- LI- IL�J iILI,J Project Specific (specify):-------.-.--�_ .. ..-_.. _ - v�._._._: - <br /> Normal " RushU) <br /> q y 2 Date: z�i S 4 6 1 . Received by 28 Date: Z <br /> (Signature/AffAliabonl a^-��d rr Gog-P Time:- --i ZrJ�.� ¢. (Signature/Affiliagonl r �f �" l Time: /,I'e /' d <br /> u <br /> 2. Relinquished by Date: _ _--------T 2. Received by �, tY:,F. ,.' Irtfr.tf? <br /> (Signature/Affiliatiool Time: {signature/Affiliation] <br /> 'Al IV <br /> 111 <br /> 3. Relinquished by Date: -----__ <br /> -- 3. Recei Received � <br /> (Signature/Affl ationl Time: _-'-- [Signature/Affiliation)oCOOD CONDnON- <br /> OPRWET, e <br /> Comments:29 HEAD SPACE <br /> MCA 3f 15191 <br />