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rr r rr r■ r r r ■r r ■r ■r rr rr rr �r <br /> i4 AMONAL ANALYSIS REST AND Reference Document N 1 <br /> TECHNOLOGY "�# r §T3 <br /> ® CHAIN OF CUSTODY RECORD* 0?� Pae 1 of I <br /> coRroRAT><oN g <br /> `732-19 oz000aoo <br /> Project Name/No 1 C CE Samples Shipment Date 7 4 !O 9 S Bill to 5 Joy,. �-- <br /> Sample Team Members?� C� Lab Destinations S� r— GAS a <br /> Profit Center No 3 Lab Contact 9 <br /> Project Manager4jcap 2r Project Contact/Phone 1 _ �a.ip ,Report to 10 <br /> M <br /> Purchase Order No s Carrier/Waybill No 13 "Ca,_,O ,v <br /> Required Report Date 1 IJar' _ <br /> Sample 14 Sample 15 Date/Time16 Container) Sampler Pre- 19 Requested Testing 20 Condition on 21 Disposal 22 <br /> Number Description/TypeCollected Type Volume servative Program ReceiptRecord No. <br /> I ` HGtots <br /> O►oq w GIMUIIIIAL,_o.J V_ ANC VOCE 140.4_ Ex Sarno <br /> 47A5 RNM aft momIMUR <br /> r M or <br /> 451p a <br /> M <br /> Q05 <br /> otoll!Aw <br /> 115c) <br /> '61CA <br /> 1 192C n I V <br /> "r," rim M= MW W" a <br /> rr <br /> n <br /> Special Instructions 23 <br /> Possible Haz rd Identification 24 Sample Disposal zs Er <br /> Non-hazard � Flammable CJ Skin Irritant Poison B ❑J Unknown Return to Client❑J Disposal by Lab Archive (mos ) m <br /> Turnarou d Time Required 26 CC Level 27 m <br /> Normal Rush LJ I l J II CJ III I-J Project Specific (specify). 5 <br /> 1 Relinquis 28 Date 1/10196- 1 Received by 28 Date l� <br /> (Signature/Affihataon n Time }�C°1 Z1C� (Signature/Affiliation] Tlme ! <br /> 1 L• .� 6° <br /> 2 Relinquished by Date 2 Received by Date <br /> [Signature/Affiliation] Time (Signature/Affiliation) <br /> Time <br /> 3 Relinquished by Date 3 Received by Date <br /> (Signature/Affiltauon) Time (Signature/Affiliation) <br /> Time <br /> Comments 29 <br /> AICA W W1 <br />