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® W. ATIONAL Reference Document <br /> TEc>H GLOW ANALYSIS RE EST AND W" '1043 <br /> CHAIN OF CUSTODY RECORD* Pae 1 of <br /> co�oRATIox 9 5-?S'3 <br /> Project Name/No 1 is 63zIlSamples Shipment Date 7 -a-��-9�- BIII to 5 e <br /> Sample Team Members 2R44.f?14 Lab Destinationst��' �� S_ � m <br /> Profit Center No 3 Lab Contact 4f7-r 7 T-1;11 <br /> rb ° <br /> Project Manages efL s e Project Contact/Phone (QA 7�73Report to 10 m <br /> Purchase Order No s Carrier/Waybill No 13 <br /> Required Report Date 11 !Cmanttainer'i <br /> CD <br /> Sample s4 Samples 5 Onte/Time 16 Samples pro- s 9 Requested Testing 20 Condition on 21 Disposal 22 <br /> Number Deecri on Collected Volume saruative Program Receipt Record No. <br /> io 34 C '�� ro w Jib. 06,01 of L001111 sib 1111111111110 <br /> GL r/D e (�oLo <br /> so 1,16L- <br /> CL <br /> Z/ �D g ` r pA�L rbA y4, LL �/OC 0010 <br /> ;/Z/to 305,E _ )Ayo;%�'L V.4 L CL 11P-C <br /> a qomi. ,JcL VjC (bozo <br /> �,/ /o SOS 5� Xq°"`a yooL 1.1�L l®� <br /> Ho IxyQ z =/ fJCL 1 67 C &010Cr 0 <br /> /0 30 ✓ c%/���r� co <br /> o-to /yC o `/Ort tq(L �P� <br /> 0 <br /> EP <br /> Special Instructions 23 <br /> Possible Hazard Identification 24 Sample Disposal 25 <br /> Non-hazard 1 Flammable J Skin lrritant�l Poison B J Unknown Return to ClientDisposal by Labs Archive (mos '04 <br /> Turnaround Time Required 26 QC Level 27 <br /> Norma Rush CJ I IJ 11 IJ III IJ Project Specific (specify), s <br /> 1 Relinquished by 282 Date - _3— 1 Received b 28 Date S C <br /> (Signature/Affiliation) Time �� [Signature/Affiliation] <br /> Time <br /> 2 Relinquishe y Date 2 Received by Date <br /> (Signature/AfSiiation) Time (Signature/Affiliation] Time <br /> 3 Relinquished by Date 3 Received by Date <br /> (Signature/Affiliation] Time (Signature/Affiliation) Time <br /> Comments 29 <br /> MCA arl"I <br />