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00 Chain t., <br />N Custody Record <br />STL-4124 (0901) <br />Client <br />Address <br />qq-S 1 <br />C <br />�. <br />i State Zip Code <br />o e.e,VIICA ? <br />Pro/act Name and Location (State) <br />tDI LY R.Pr S, 4- DEi3R-tS• �`rae <br />,v <br />3 <br />CD <br />0 <br />m <br />w <br />v <br />w <br />cn <br />rn <br />0 <br />Sample I.D. No. and Description <br />(Containers (or each sample may be combined on one line) <br />e3 0-71ob5r <br />Telephone Number (Area Code)/Fax Number <br />16-1171-3194 '0 <br />Site Contact Lab Contact <br />p)L.t'k <br />Matrix <br />Date Time p <br />t/a.r tyt+.r �S <br />STL <br />Severn Trent Laboratories, Inc. <br />Date <br />n <br />Lab Number <br />ag Analysis (Attach list if <br />Preservatives <br />A <br />1 ,01, r <br />N Custody Number <br />143629- <br />/ of ) <br />Special Instructions/ <br />;0nrdtlans — Reeeipl <br />aS <br />--AJ ek C co tip <br />LJ it►� <br />Possible Hazard Identification <br />,,.t <br />C2Non-Hazard❑ Flammable r.Q Skin Irritant ❑ Poison B ❑ <br />Unknown <br />Sample Disposal <br />❑ Return To Client <br />❑ Disposal By LabArch/ve For <br />(A tee maybe assessed it samples are retained <br />Months longer than 1 month) <br />Turn Around Time Required <br />❑ 24 Hours ❑ 48 Hours <br />❑ 7 Days ❑ 14 Days ❑ 21 Days <br />UO (LrA-- <br />0 other <br />OC Requireme (Specify) <br />1. Relinquishe Sy <br />. <br />�.. 1S <br />Date <br />Time <br />t. c <br />Date <br />Time <br />2. Relinquis By <br />Date <br />Time <br />,ved By <br />Date <br />Time <br />3. Relin ished <br />, Date Time <br />13. Received By <br />Date <br />Time <br />cn - <br />0 <br />4 DISTRIBUTION: Vvw'TE - Returned to Client with Report: CANARY • Stays with the Sample. PINK • Field Copy <br />