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.� Ir ilii iii �^i i� r iltlir r m wo ism m r r � <br /> ® INTERNATIONAL ANALYSIS REQUEST AND Reference Document$Qo."r7;71m'` <br /> TECHNOLOGY CHAIN OF CUSTODY RECORD* Page 1 of <br /> CORPORATION <br /> == <br /> 1 `_ , MM1?Ct1 L_14NE TACK' 6P I I- 5�/ ql Bill to: . —IT C41�Y <br /> Project Name/No. � • Samples Shipment Date .1�.R� F.�«IEco �•�v� _ <br /> Sample Team Members 2 D '�""`'0A' Lab Destinetlon 8 � +oa I�INM`r'"`'°t ►�Flr�T ►,�� ��� <br /> CJa 4 y <br /> Profit Center No. 3 � I Lab Contacts ►'� �`'E c t 10 W <br /> 4 �. ►--111 5 1Z �.MI���(s1o�377 q1W <br /> Project Manager Project Contact/Phone Report to:10 =YDIJE v "I<<� <br /> Purchase Order No.6 Carrier/Waybill No.'13 'cou " ( ►a= A�vc) <br /> Required Report Date 11 <br /> a <br /> Sample 14 Sample 15 Date/rime16 Containers 7 Sample E Pre. 19 Requested Testing 20 Condition on 21 Disposal 22 <br /> Number Description/Type Collected Type Volume servathm Program Receipt Record No. <br /> 112(09 l�-�I II zG9f 1040 6.�uBt °k(ow • <br /> �COq I Sol L IblS w= oft woo <br /> OIL Q &ZEASE-55W TE <br /> ST LC "tlAl5 17 -(,old <br /> �1 L 10 - <br /> c <br /> � { ILLI l <br /> Ot6 <br /> L L 06 <br /> I <br /> -tF}l(b5 <br /> 110$ I JOB: <br /> T" 9ezb oa 87,16 qnw Ilaw smco <br /> (D <br /> TGAP"6•, Mc cd,cm, Q <br /> m <br /> • Ft B,F�'P,F#lA,cEecLoic � <br /> - O <br /> Special Instructions: 23 Cr 3 <br /> Possible Hraz�d Identification: 24 ' ".Sample Disposal: 25 0 <br /> Non-hazard J Flammable J Skin Irritant �J ." Poison 8 J Unknown g Return to Client J Disposal by Labe Archive (mos.) M <br /> Turnaround Time Fjequired: 26QAC Level:27 L <br /> Normal J RushAJ 11i.IJ Project S ecifi (specify). N <br /> 1. Relinquished b 28 Date: I I z?-ql , 1. Received by 28 Date:�17 I <br /> o q <br /> (Signature/Affiliation) �,. JT-F Tlme: (SiB�atufe/Affiliation) Time: !4 4.4 / o <br /> O <br /> 2. Relinquished by Date: 2..� Oived by Date: in <br /> (Signature/Affiliation] Time: (Sig Affiliation) .7 Time: <br /> 3. Relinquished by Date: 3., Received by Date: <br /> (Signature/Affiliation) Time: (Signature/Affiliation) „ ,'' Time: <br /> Comments:29 1, <br /> T <br /> MCA 3/1551 <br />