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rw w ■w w � w wr iw �Iw rw �w w� w <br /> No <br /> 20299 <br /> SEVERN TRENT LABORATORIES F T <br /> (omm,,,edTo3aat4vCHAIN eces5 0 CUSTODY RECORD <br /> CUSTOMER INFORMATION PROJECT INFORMATION <br /> COMPANty:7— r PROJECT MEIN MBER fC 1��3 0) R <br /> SEND REPORT TO f T z �� <br /> h BILLING INFORMATION Q h <br /> �4U <br /> ADDRESS C ,f BILL TO � r z y JIVcl <br /> ffW ADDRESS <br /> y <br /> 0 =Q LAB JOB NO <br /> 0 <br /> cc Q <br /> PHONE m <br /> FAX ZS U -� FAX PO NO <br /> 63Z <br /> SAMPLE NO SAMPLE DESCRIPTION SAMPLE SAMPLE SAMPLE DATE MEMATRIX CONTAINER PRESERV REMARKS/PRECAUTIONS <br /> TIME <br /> 0 r /� -7 L- S <br /> Q &I vi <br /> 1 30 LayVX <br /> Q <br /> U <br /> w SAMPLER SHIPMENT METHOD AIRBILL NO <br /> CC <br /> w REQUIRED TURN ROUND' ❑SAME DAY ❑24 HOURS ❑48 HOURS ❑72 HOURS ❑5 DAYS ❑10 DAYS ❑ROUTINE ❑OTHER r <br /> 1 RELINQUIS ED Y DATE 2 RELINQUISHED BY DATE 3 RELINQUISHED BY DATE <br /> � SIGNATOR SIGNATURE SIGNATURE <br /> 0 <br /> o PRINTED NAMEICOMPANY TIME PRINTED NAMEICOMPANY TIME PRINTED NAMEICOMPANY TIME <br /> 0 <br /> 1 RECEIVED BY DATE 2 RECEIVED BY DATE 3 RECEIVED BY DATE <br /> SIGNATU /J -;? SIGNATURE d21��r1 SIGNATURE <br /> cnx <br /> !� <br /> TI <br /> PRINTED A 7ENI t PAN, E� PRINTED NAMEICOMPANY �� TIME f PRINTED NAMEICOMPANY TOME <br /> SEVERN TRENT LABORATORIES <br /> 1721 South Grand Avenue <br /> Santa Ana, CA 92705 <br /> Phone (714)25&8610/Fax (714)258-0921 <br />