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• �1 <br /> CHAIN OF CUSTODY No. 100217 Page-1—of—j— <br /> CONSULTANTS NAME CON `UL[T�ANT'S ADDRESS _ ,, <br /> f3 }`t141e Qc t.vy> �i� Ga R� {'r� v �C_ <br /> BP SITE NUMBER BP SITE/FACILITY ADDRESS CONSULTANT PROJECT NUMBER <br /> 1193 3za-L ti . IV7W Gtr ck � cA- 4qID/j ?-TZ__ <br /> CONSULTANT PROJECT MANGER PHONE NUMBER FAX NUMBER CONSULTANT CONTRACT NUMBER <br /> BP CONTACT BP ADDRESS PHONE NUMBER FAX NO. <br /> LAB CONTACT LABORATORY ADDRESS PHONE NUMBER FAX NO. <br /> BP CONTACT REQUESTING RUSH TAT(Print BP Contact Name) RUSH REQUESTED OF(Print Consultant Contact Name) DATEJTIME SHIPMENT DATE SHIPMENT METHOD <br /> L NUMBER <br /> TAT: 24 Hours 48 Hours 72 Hours Standard 7 or 14 Days ANALYSIS REQUIRED AIABIL <br /> AI r _ X gn 39 gg ply <br /> CONTAINERS PRESERVATIVE y <br /> SAMPLE DESCRIPTION COLLECTION COLLECTION MATRIX( <br /> GATE TIME SOIIJWATER TYPE LAB �!A COMMENTS <br /> NO. (VOL.) SAMPLE# <br /> 10, &1 ala.,, K <br /> Q it <br /> i Lp <br /> uu <br /> r <br /> SAMPLED 8Y(Please Print Name) p ,y SAMPLED BY(Signature) ADDITIONAL COMMENTS <br /> SVIA, —A� <br /> RELINQUISHED BY 1 AFFILIATION DATE TIME ACCEPTED BY/AFFILIATIONI <br /> (Print Name 1 SignI <br /> ature) (Print Name/Signature) <br /> DATE TIME <br /> GLV-16722-A{2197) — <br /> PKG150 DISTRIBUTION: WHITE-ORIGINAL(WITH DATA) YELLOW BP PINK-LAB BLUE-CDNSULTANT FIELD STAFF <br />