Laserfiche WebLink
INTERNATIONAL ANALYSIS REQUEST AND Reference Document No 4 2 9 2 17 <br /> co ORATION CHAIN OF CUSTODY RECORD* Page 1 of <br /> Project Name/No 1 S3 C L'ENErAQ Y Samples Shipment Date 7 5- 1( -9`7 Bill to s <br /> Sample Team Members_2 ,NQS ��;I( S_ _ Lab Destination s_G J L_L j p�S _3_�3t4 <br /> Profit Center No 3 Lab Contact 9 JOliN bUC E <br /> Project manager4 .�dp Project Contact/Phone 12 se <br /> J Report to 1° _ <br /> Purchase Order No 6 Carrier/Waybill No 13 HIS D�LIVEe�� <br /> Required Report Date 1I—N%M INL - <br /> i <br /> Sample 14 Sample 15 Date/Ti 16 Container) Sample) pre- 19 20 <br /> Number Descri tion/T a Collected T e Volume servatnre Requested Testing Condition on 21 Disposal 22 <br /> Program Recei t Record No <br /> 0-15Vwol GROUNDVATEA 5-11 q�130 VCA an 3kwnd NCL -rVH-v %c%S- <br /> brc-x 190ZD E5( <br /> 0-513 VWOZ 1630 J rP11- o►s _ <br /> 0515 WELL bL ! 3p 5,00 � M <br /> '� ' I w <br /> Special Instructions 23 <br /> Possible Hazard Identification 24 <br /> Sample Disposal 25 <br /> Non-hazard Flammable IJ Sian Irritant IJ Poison B {J Unknown I Il Return to Client IJ Disposal by Lab Archive (mos ) <br /> Turnaround Time Required 26 DC Level 27 <br /> Normal xj Rush _J I I J !!I J ll! IJ Project Specific (specify) _ w <br /> 9 Relinquished by 28 - Date _.51�5 9 7 — '1 Received b 2a - - - - tel_ <br /> [Signature/AFfiLatton) �'' Time L?00 [Signature/Aifiliahon)Y Date <br /> Time <br /> 2 Relinquished by Date �6_fq 2 Received b ��� <br /> [Signature/Affiliation) f , } Time <br /> : y Date <br /> u./ ,�j y� (5tgnature/Affihatton) Time <br /> 3 Relinquished by Date <br /> _ 3 Received by Date <br /> Signature/Affiliation) Time [Signature/Affiliation) Time <br /> Comments 29 t O 30 <br /> v o,q s 6q)14 L 4p 05'1 S tj�F L,-o 2, 1C. <br /> D <br /> MCA 3!1"J <br />