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CHAIN-OF-CUSTODY RECORD AND REQUEST FOR ANALYSIS No. <br /> McCULLEY, FRICK & GILMAN, INC. <br /> ❑ 737 29th Street,Suite 202 ❑ 524 Bank Street,Suite 207 ❑ 5818 Balcones Dr.,Suite 202 5 Third St.,Suite 400 <br /> Boulder,CO 80303 Wallace,ID 83873 Austin,TX 78731 San Francisco,CA 94103 <br /> TEL:(303)447-1823 TEL:(208)556-6811 TEL:(512)371-1667 TEL:(415)495-7110 <br /> FAX:(303)447-1836 FAX:(208)556-7271 FAX:(512)454-4126 FAX:(415)495-7107 <br /> PROJECT No.: OJECT dAME: ! / PAGE: OF' —2— <br /> SAMPLER <br /> SAMPLER(Signature) PROJECT MANAGER: -�--- DATE: �C <br /> METHOD OF SHIPMENT: CARRIER/WAYBILL NO. DESTINATION: ! <br /> SPECIAL INSTRUCTIONS/HAZARDS: <br /> SAMPLES ANALYSIS REQUEST <br /> Preservation Containers" Methods Handling REMARKS <br /> 0 0 0 0 `— m (Special handling <br /> Sample co m procedures,specific <br /> Lab Sample Collection d C E 0 o N N 0 0 o analytical methods, <br /> o w w w to ro co o 0 0 X o = z observations,etc.) <br /> No. Identification DATE TIME Matrix• _ = O z o O d a era w Lu F- a ~ O c ►a- I.53 <br /> z w wwwf— f— m = ac cn <br /> So B I <br /> S IS ?� (V <br /> -to- yb 1 x -13 <br /> -��_ � 2•J So <br /> y-/S.S-A- v R <br /> SO lit <br /> S SO I'3 l� <br /> v <br /> 0 <br /> ENTSI CONDITION 0 <br /> F9AMPL <br /> s t <br /> a C 4 <br /> BO TORY COMM 0 f <br /> TOTAL NUMBER OF CONTAINERS <br /> LA V 0. <br /> . . . <br /> r� r2 [ , ago <br /> RELINQUISHED BY: DATE TIME RECEIVE BY• <br /> SIGNA UR PRINTED NAME COMPANY SIGNAT R PRINTED NAME COMPANY <br /> �� � e.................. <br /> LABORATORY <br /> Matrix AO-aqueous A-nonaqueous SO-soil SL-sludge Ppetroiaum A-air OT-orh9r Containers Pplastk G-plass T-teflon B-brasscher <br /> DISTRIBU77 PINK:Fiald Copy YELLOW:Laboratory Copy WHITE., alum to Originator <br />