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Chain of <br />Custody Record <br />Ln <br />0 <br />STL <br />Severn Trent Laboratories, Inc. <br />STL-4124 (0901) <br />Client <br />rL C <br />Address <br />4- n <br />City State I Zip Code <br />Project Name and Location (State) <br />�J C. C� �1 O 2-� S <br />ContractIPurchase OrdedOuote No. <br />Sample J.D. No. and Description Date <br />(Containers for each sample may be combined on one tine) <br />Project Mana er <br />P; �►a <br />Telephone Number (Area Code)/Fax Number <br />`� L- 3Z�4 "'f �f �f �) 3'7Z—IUJ9Page <br />Site Contact lab Contact <br />CarrieryWaybill Number <br />Containers <br />Matrix Preservatives p <br />Time y E" <br />I T z NZ <br />11 1 174 <br />I I I X 1 <br />I I L <br />Date Chain of Custody Number <br />31 gloms 1-43 546 <br />Lab Number <br />of <br />Analysis (Attach list if <br />more s we is needed <br />So edal lnstnolctiensf <br />Conditions of Receipt <br />L <br />❑ 24 Hours ❑ 48 HOWS <br />By <br />❑ 7 Days ❑ 14 Days [:121 Days Other <br />Dale` <br />Time <br />1. Recei 8 <br />Dat <br />3 / <br />Time <br />1. Relinquished <br />3[ U�µ <br />I <br />G <br />2. Relinquished By <br />Date <br />Time <br />2. R ed <br />Date <br />Time <br />3. Relinquished 8y <br />Date I <br />Time <br />. Received By <br />I Date <br />Time <br />I <br />Possible Hazard Identification <br />El Non -Hazard [I Flammable Skin Irritant ED Poison 8 <br />❑Unknown <br />Sample Disposal (A fee may be assessed if samples are retained <br />❑ Return To Client ❑ Disposal By Lab Archive For Months longer than 1 month) <br />OC Requirements (Specify) <br />Turn Around Time Required <br />t <br />�� <br />❑ 24 Hours ❑ 48 HOWS <br />By <br />❑ 7 Days ❑ 14 Days [:121 Days Other <br />Dale` <br />Time <br />1. Recei 8 <br />Dat <br />3 / <br />Time <br />1. Relinquished <br />3[ U�µ <br />I <br />G <br />2. Relinquished By <br />Date <br />Time <br />2. R ed <br />Date <br />Time <br />3. Relinquished 8y <br />Date I <br />Time <br />. Received By <br />I Date <br />Time <br />I <br />°1 Comments <br />V <br />O <br />the Sample: PINK -Field Copy <br />4 DISTRIBUTION; `: - Returned to Client with Report. CANARY - Stays with <br />