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Chairs-of C ustody Number: <br /> SECOR Chain-of Custody Record <br /> C �Additionall€focurneents are attached, and are a part of this Record. <br /> .Field Office: r _ <br /> Address: 0 e W D•7 f e), n e r, � �f r � � � Job Dame, <br /> Location. e- <br /> 54 <br /> c - All,,, C <br /> Project#5-d D�?0 o/Task# Analysis.Request <br /> Project Manager /V n ry 13rg- _ <br /> N <br /> Laboratory °° ® s <br /> C <br /> Turnaround Time 21 <br /> ' 2m U <br /> a LS ss <br /> 'i7 _ <br /> w �r ao <br /> Sampler's Name UJ a ; n a o Id. a n a <br /> Sampler's Signatur "Z., <br /> -o o CU m a <br /> r z r — E50 w- 15 c;, o•. Comments/ <br /> IL C'J <br /> Sample ID rD;ate Time Matrix ¢ ° Instructions z <br /> ] — <br /> 106 )1:=0 W t <br /> Special Instructions/Comments: Relinquish Rece' b Sample Receipt <br /> Sig Sign Total no.of containers: <br /> Prin r Print i -. �E Chain of custody seals: <br /> Company s= Company Rec'd.in good condition/cold: <br /> Time 3 Date —Z Time t : 0 Date Conforms to record: <br /> Retia he Received by: <br /> Sign Sign Client: <br /> Print Print Client Contact: <br /> Ccsmpat�y Company <br /> Time <br /> �(ctkDate Time Date Client Phone: <br /> SECOR CUSTREC Rev 1195 <br /> Date: ]x I 2 g 224L Page f of <br />