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CHAIN OF CUSTODY N0.07710 7 Page ` of 1 <br /> CONS LTANT'S NAME ADDRESSJN� CITY ,STATE ZIP E <br /> S r— Lt <br /> BP SITE NUMBER BPC RNER ADDRESSI ITY CONSULTANT PROJECT NUMBER <br /> CONSULTAN PROJECT MANAGE PHON UMBER FAX NUMBER CONSULTANT CONTRACT NUMBER <br /> BP CONTACT— BP ADDRESS PHONE NUMBER FAX NO. <br /> �—CUA <br /> LAB CONTACT * LABORATORY ADDRESS PHONE NUMBER FAX NO. <br /> SA LED BY(Please Print ame) SAMPLED {Signature) SHIPMEN DATE HAIRBILL <br /> IPMENT ETH <br /> OD <br /> — ? -1 <br /> NUMBER <br /> TAT: ❑ 24 Hours ❑ 48 Hours ❑ 1 We Standard 2 Weeks ANALYSIS REQUIRED <br /> COLLECTION CONTAINERS PRESERVATIVE <br /> DATE MATRIX <br /> SAMPLE DESCRIPTION SOIUWATER FTYPE LAB 1— <br /> COLLECTION rr COMMENTS <br /> NO. <br /> SAMPLE# }f <br /> TIME 111 111111 <br /> •- 1 �� �..f �' I <br /> =Z <br /> ADDITIONAL COMMENTS <br /> R INQUISHED BY I AFFILIATIO DATE TIME ACCEPTED BY t AFFILIATION DATE TIME <br /> 0&V,�-, o <br /> C- ` <br /> IWa <br /> CLV-16722 Distribution: White-Original (with Data) Pink-Lab <br /> PKGI50 Yellow-BP Blue-Consultant Field Staff <br />