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Sample Chain-of-Custody/Analysis Request Kennedy/Jenks Consultants <br /> ls) <br /> Possible Hazards Analyses Requested <br /> Client Report to Lab Destination <br /> Site Company Address <br /> Project No. Address <br /> Sampler Name li Telephone <br /> Telephone Fax ' ' Carrier/tNay Bill No. <br /> (7} (1) Collection (2) (3) (4) Turn- Comment/Conditions <br /> Lab ID No. Client ID No. Date Tlme _ Type De Pt <br /> Comp. Pres. around (container type;container number,etc.) ' <br /> (t) Write only one sample number in each space. (4) Preservation of sample. <br /> (2) Specify type of sample(s):Water(W),Solid(St or indicate type. (5) Write each analysis requested across top,Place an'X"in appropriate column to <br /> (3) Mark each sample which should be composted In Laboratory as follows:Place an"Vin box for each sample that should be composited into one sample,use sequential letter for additional groups. Indicate type of analysis needed for each sample. <br /> Sample Relinquished By Sample Received By <br /> Print Name .Signature Company Date Time Print Name Signature Company Date Time <br /> Kennedy/Jenks Consultants,Inc.0 2001 <br />