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NERSSMIA M 777!209 <br /> 806 North Bat=a ■Chain of Custody Record Phone (7I4) 771-690 <br /> Company T,r ai Pe(- i G C�Q- Phone Kc-? — A L Job No qVS1-7 Page of <br /> Protect Manager Fax Z. <br /> q_J L <br /> 2 -16W <br /> Analysis Requested Test Instructions& Comments <br /> Protect Name �1� ^ -� iA c, � S z Protect � ,L <br /> and Name �Z <br /> Site /t�L�6 1" P �`�L + — <br /> P �pp <br /> Address V Chi <br /> Sample ID Lab ID Date Time Matrix Container Pres Q <br /> Number/Size 1 <br /> zVw—2 to; <br /> 0'. <br /> a <br /> to, X <br /> s U1 j! old X <br /> 7V w—kC, Ja i <br /> Z01 I XI Y <br /> 9 11N V —6-6 a ��- Xy x1 )CI <br /> 11 U � �`L�lo X <br /> 13 v <br /> 14 <br /> 15 <br /> Sample Receipt-To Be Filled By Laboratory Relinquished byG/+ p 1 Relinquished b 2 Relinquished by 3 <br /> 6 <br /> Sampler - C, t� <br /> Total Number of Containers Property Cooled Y/N/ A Sign a Signature U �` Signature <br /> Custody Seals Y/N/NA Samples Inta /N/NA Printed NamePrinted Name Printed Name <br /> Received In Good Condition Y/N Samples Accepte Date <br /> e •-0d .O Time Date Time Date Time <br /> Turn Around Time Received sy t Received By 2 Received By 3 <br /> Signature Signature O Signature <br /> �/ 011 <br /> L7 Normal ❑ Rush Same Day ❑48 hrs Printed Name Printed Name) Printed Name <br /> ❑24 hrs El 72 hrs I r) 4A'1 <br /> Date Time Date Time Date Time <br /> r <br /> Distribution White Laboratory Canary Laboratory Pink Project/Account Manager Goldenrod sampler/Onglnator <br />