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eace4knaimt ��_ CHAI&F-CUSTODY 1 Analytical Request Doonent <br /> AV <br /> The Righl Chenirstr}; The Right Sohrlion The Cham-of Custody is a LEGAL DOCUMENT All relevant fields must be completed accurately <br /> 7 0 <br /> Required Chenl Information Section A Required Client Information Section B of To Be Compleled by Pace Analytical and Client Section C <br /> Company r Report To Quote Reference <br /> - [,, <br /> ��` Client tnlormalion Gheck uotelconlrac <br /> Addres Invoice TO Roquesied Dye ate 7AT Prolecl Manager <br /> ti "J f a vt <br /> P <br /> QaA a V..,_1 /ip�� C Prolecl M <br /> 67` 'Under I A day turnaround subject io laboratory and O D <br /> contractual obligations and may result in a Rush <br /> Project a e Turnaround Surcharge Prolity p <br /> PhonOFax Tum Around Time(TAT)m calender drys <br /> 7,� O � �� Pro3ecS N J �l Requested Analysis <br /> Section d Required Client information Valid Matrix Codes 4 <br /> - o o Preservatives <br /> MATRIX CODE , <br /> wnIL WT w w <br /> SAMPLE I D solL SL o a w w <br /> OIL OL U o_ -i z `� <br /> WIPE INP X O V m N O <br /> One character per box AIA AR Tr C) c w N <br /> w (A-Z 0-9/ -) TISSUE TS ¢ a o O <br /> H Sample IDs MUST 8E UNIQUE 07HhR QT 15 <br /> mm l dd l yy mm hh alp T x z Z Remarks 1 Lab ID <br /> r 1 <br /> v� S ggiDo, <br /> w� <br /> - r <br /> t <br /> wgD I cool, <br /> 4 <br /> 2fJo� <br /> 7/ Ie'3�a <br /> O -JArcepted By/Company <br /> Temp In°C <br /> ev cepted By 10 <br /> Received on ICE Y / N <br /> 25 LO1 a + , <br /> Sealed Cooler Y / N <br /> Samples Intact Y 1 N <br /> Additional Comments SAMPLER NAME AND SIGNATURE <br /> PRIN�Name of SAMPL R <br /> 0,C CJQAe ►� 4l �L <br /> SIGNA7V[TE o MPLER DATE Signed {SAM!Dp 1 YY] <br /> 1 <br />