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® INTERNATIONAL L ["� 0 <br /> TECHNOLOGY ANALYSIS REDDEST AND j Reference Document No . 3 3 3 5 5 8 <br /> CORPORATION CHAIN OF CUSTODY RECORD * Z � Page 1Tof � <br /> Project Name/ No 1 ` -7C [ (765g56) ampler Shipment Date U I 1w5 I � _ Bill to 5 fte LvAa_ t: <br /> �� e - - <br /> Sample Team Members 2 q v i of .S Lab Destination II rht In e 3_b 3 tic ¢�i4\ <br /> Ie r SI _ ld�z�t`°, <br /> O <br /> 3 I t ys� � '�� c o� 256 5 S _ _ <br /> Profit Center No . Lab Contact 9Tevlhtiar M ; Ilex 6 - �— 8 <br /> �pp <br /> Project Manager Toe CCa +, q � e Project Contact/Phone 12Te Y�aMn. � \ 6j •.L3ep, o <br /> ort to : Toe in"'° ty, <br /> Purchase Order No . �� 5 } S Carrier/Waybill No . 13 b <br /> Required Report Date 11 1VJrrAi j � qS a Ove <br /> Sample 74 Sample 15 Date/Time 16 Container' Sample ' E Pre- 19 <br /> Number Requested Testing 20 Condition on 21 Disposal 22 <br /> Description/Type Collected Type Volume servative Program Receipt Record No. <br /> ST 'SSI - 00 5 5 1 3I � 6 F (Qsh' c �irg6lb Ak�i I "els A-v <br /> SSA - S61 — Diu <br /> (�3 c�. ' v Seeve- qs pkal 0- <br /> I <br /> STl} - S� j - �j 1131960 5� a <br /> � OLU <br /> f ' 592 0 ( U <br /> �l ULL� <br /> SJ✓} — <br /> 562, ' W5 13116 <br /> ( Dl � -v U7 <br /> T13 3 `� c <br /> D( Ilk <br /> U J ' -V " <br /> J.Tf} — .5133 - 0 ( � la 96 <br /> 6) ' DZ� 131y6 T n5 <br /> 5ZAS <br /> ( 35 l 095T o <br /> Special Instructions : 23 3 <br /> Possible Haz d Identification : 24 Sample Disposal 2e <br /> Non-hazard Flammable J Skin Irritant J Poison B J Unknown I J Return to Client ' J Disposal by Lab a Archive ( mos . ) o <br /> TurnaroL}d Time Required : 26 DC Level : 27 <br /> Normal QJ Rush J ly (s eci ) � s <br /> J8 .. C �� <br /> 1 . Relinquished by , [bate : � '� � � II . i 1 IIIRece[ved beC28 Specific Date : <br /> _�j <br /> [Signature/Affiliation) / ' z i %,- Time . `7 � , . J ISgnature/Affiliation] _ /. - -_ <br /> { _ Time : �� 0 <br /> 0 <br /> 2 . Relinquished by ( Date : J `� - Q 2 . Received by Date : I 155 <br /> [Signature/Affiliation] ���r' , - - _ -_ <br /> Tim <br /> ` _ _t _rte „___ - 3 . Received b Date : <br /> Time : [Signature/Affiliation] , <br /> 3 . Relinquished by � Date : � Date : _ <br /> (Signature/Arr iiatiun7 Too <br /> tsignature/Affratiun]y �L /L-- Time 1/d. . <br /> " ,`l L Z- <br /> Comments : 29V <br /> '�"� � l � tse� t}uc_ U ill � •tt <, plfs �-4. �ts u\ � f- eE.� . <br /> - MCA <br />