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CHAIN OF CUSTODY No. 10 0 7 3 5 Page--,L of 3-- <br /> CONSULTANTS NAME CONSULTANTS ADDR�oS <br /> BP SITE NUMBER BP SITE I FACILITY ADD SS T/! CONSULTANT PROJECT NUMBER <br /> 3 boeneLn - 4 �-m C!4- gsa - is 3 b <br /> CON)rjtANT PROJECT A GER PHONE NUM�JR FAX NUMBER CONSULTANT CONTRACT NUMBER <br /> .0 1r�iw Y334W 01-0 l <br /> BPTOTACT BSul 5- ! �f f� I�� P ONE�UMB�$ FAX NO <br /> LAB CONTACT LABORATORY ADDRESS cPHONE NUMBER FAX NO <br /> c -ul PA <br /> JA/h <br /> BP CONTA REQ ESTING RUSH TAT(Print BP Contact Name) RUSH REQUESTED OF(Pr Consultant Contact Name) DATEITIME SHIPMENT DATE, SHIPENT METHOD <br /> AIR ILL NUMBLR _ <br /> TAT 24 Hours 48 Hours 72 Hours Standard 7 or 14 Days ANALYSIS REQUIRED �(p _ 6 7,7,3 <br /> CONTAINERS PRESERVATIVE L <br /> SAMPLE DESCRIPTION COLLECTION COLLECTION MATRIX COMMENTS <br /> DATE TIME SOIUWATER NO TYPE LAB <br /> (VOL) SAMPLE# <br /> 61-ifs 1-p SL/6v <br /> CA A16 �a <br /> 2-0' <br /> -r - &H12 qz D (o � <br /> CR-/ - Ail .� <br /> c9-2, - 0 ,L if <br /> -A - la t <br /> SA BY(PleaPrint Dame} SA D ( gnatur ADDITIONAL COMMENTS <br /> n2 <br /> RELINQUISHED BYIAFFILIATION ACCEPTED BY/ TION <br /> rent Name I Signature) DATE TIME (Print Name S g ure) DATE TIME <br /> CLV 16722 A(2147) <br /> PKGl50 DISTRIBUTION WHITE ORIGINAL(WITH DATA) YELLOW BP PINK LAB BLUE CONSULTANT FIELD STAFF <br />