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.�. T11MMONAML <br /> i. rr .� r <br /> OioANALYSIS REQUEST AND *,. Feterenceum Nc <br /> ® TEC CHAIN OF CUSTODY RECORD Page 1 of <br /> CORPORATION U fl?Z Z <br /> Project Name/No. t� h1q�c� h e Samples Shipment Date- / Bill to: <br /> p L <br /> Sample Team Members 2 k = Lab Destinations ��� �-S!°� <br /> Profit Center No. 3 I '' Lab Contact 9 �� �'�'�� S�� 36 <br /> lic <br /> Project Manager S C/he /V/l-S Project Contact/Phone 12� /i/S Report to.i� --- <br /> Purchase Order No. s — - Carrier/Waybill No. 13 lo�ir'/G''y S <br /> P 5 1,7 ,efra /v <br /> Required Report Date ll4 lo 1 - c <br /> Gf �7l � <br /> Sample 14 Sample 15 Date/rime16 7ntal.ner,' Samplel7Pre- �. Requested Testing 20 Condition on 21 Disposal 22 <br /> Number Description/TypeCollected Voluloft <br /> me Program Receipt Record No. <br /> • r IrO7� UZIC <br /> ton <br /> �3 l <br /> c <br /> a <br /> C <br /> - .. C' <br /> C .. ,. C <br /> C <br /> Special Instructions: 23 rG/-SSI 7'ZI, ANN, Z <br /> Possible Hazard Identification: 24 Sample Disposal: 25 s <br /> Non-hazardA Flammable J Skin Irritant J Poison B U. Unknown J Return to Client J Disposal by La.14 Archive (mos.) <br /> Turnaround Time equired. 26 OC Level:27 <br /> Normal Rush -e/4 r • II.IJ III.❑J r= Project Specific (s eci ) <br /> 1 . Relinquished by 28 e ! 2 �// 1. Received by 2s Date:/z z 9/ <br /> (Signature/Affiliation] Time: J (Signature/Affiliation] ,� Time: DO <br /> 2. Relinquished by< `�, -. Date: /Z > 2. Received by Date: �� 3 R I <br /> (signature/Affiliation) ✓i;� /`7 T Time: rJ (Signature/Affiliation] Time: L/O �.� <br /> 3. Relinquished by Date: 3. Rsceived by Date: <br /> [Signature/Affiliation] Time: (Signature/Affiliation] Time: <br /> Comments:29 <br /> MCA 3115191 <br />