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INTERNATIONAL 4 1 1 2 0 2 . 50A <br /> TECHNOLOGY ANALYSIS REQUEST AND Reference Document No. 3 3 7 9 4 3 <br /> CORPORATION CHAIN OF CUSTODY RECORD* Page 1 of <br /> Project Name/No. 1 CA�+u/190976 Samples Shipment Date z �C�t"� ui= 1 Z-Z 41 5 <br /> Bill t0: �� Cq r_ATIO&j <br /> Sample Team Members-2 +�. -BiANwnl Lab Destination 8 _— ►cam , �.b�114To 4��5 1cH g,��• <br /> Profit Center No. a -' 4 1 Lab Contact 9 c'Afzwi � &MAG IA2T�yq, CA 94� v <br /> Project Manager° -T-i" ANON Project Contact/Phone 12--r. ANEJJSOnI/�a)37Z•91oo 0 <br /> =1- COIiyP, <br /> Purchase Order No. 6 Report to:10 3Carrier/Waybill No. 13 C a.-5- <br /> Required Report Date 11 12-S-Q 1 <br /> - 5 LIN MO.. 3 <br /> a <br /> Sample 14 Sample t5 Date/Time 16 Container, Sample" Pro- 19 2p m <br /> Number Description/TypeCollected T Volume servative Requested Testing <br /> ttng Condition on 21 Disposal 22 <br /> ProgrRecei t Record <br /> i 12'91 M W 1 Graw�waTs3-. II-1791 1315 40.,.dM y0 Hl. HCL -�-> 4(G)/gTEX 1 z <br /> s <br /> f <br /> r <br /> a <br /> n <br /> 0 <br /> I p R I -r-F-H (t�) <br /> ppyya�d ,L <br /> -MJMt FStY 500MC Y'cC CNlA21D�g Tj�S ... <br /> m <br /> N IT214Tt� <br /> m <br /> x <br /> Special Instructions: 23 0 <br /> Possible Hazwd Identification: 24 3 <br /> Non-hazard-,J, Flammable Sample Disposal: 25 0 <br /> J Skin Irritant J Poison B J unknown J Return to Client J Disposal by Lab J Archive <br /> Turnaround Time Required: 26 CCeve,: 27 (mos.) <br /> Normal J Rusw:J- I.. IL J III. J Prdect S c (s eci ): m <br /> 1. Relinquished 28 Date: 17-Z-911. Received b 5 <br /> f&gnawra/Aff liauon) y Date: <br /> Time: <br /> 10-230 (Signature/APobapon) <br /> 2. Relinquished Time: <br /> Date: /L- i—� / 2. Received b ° <br /> (Signature/Affifiaoonl r y _ Date: m <br /> Time: Z (Signature/Affiliation) Time: <br /> 3. Relinquished by Date: 3. Received b <br /> (Signawre/Affiliation) - y Date: 12 R/ <br /> - Tlms:—._ . _.-- _ "� fsignawre/Alfiliationl -,)cc,( /�I /f�[ <br /> Comments:29 / I Time: /Z If- <br />