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I Chain-of Custody Number. <br /> SECOk Chain-of Custody Record <br /> Field Office 1071 So►crctrA2ni-a ;1 Additional documents are attached,and are a part of this Record <br /> Address. 300 Y-11 0fe RAM Stie IDD ' IG II Job Name - <br /> Qmat Co 74 I; I II location Fle PA <br /> # 7oT.436 01 Task# 00 11 10;MII Analysis Request <br /> Project <br /> Project Mana er a +erIa i ek <br /> Laboratoryi 41A C e <br /> Tumaround Time)0 6 s tan&wd a <br /> x rn W ,rn <br /> 92 i E9 3 <br /> i]r`�Q� 4.ut e = -6 Loa— <br /> Sampler'sas <br /> i Name c �� m St0 oo ttia mQ a� a <br /> Sampler's Signature v V9 m" m T , <br /> z zr = a r ESN o 3 <br /> a. <br /> SS---tf Z2 Sa i ! II pep ,d9 <br /> E <br /> ; 'Sah [e ID Date Time is z <br /> RZa' 1lo <br /> 11111145,30-10 <br /> k II <br /> I <br /> 5-13 2v' <br /> S-t <br /> 32s-' <br /> t's2n I II -r <br /> sr13 30` ZSLS �, I� 11 <br /> Special Instructions/Comments Relin " ishpd by Received-by Sam ie Receipt <br /> * 06077004 '77 Signf1k R Sign Total no of containers <br /> V all Iil \404-tLS t R C Print t S eco� Pnnt � � Chain of custody seals ' <br /> Company. Company V. r- -- pec'd in good condition/cold <br /> Time 20 40 Time 150 Dated d Conforms to record <br /> RelinquilIe by Recd d by Client <br /> Sign 31 11 s Sign <br /> PnntJ 1� Pnnt Client Contact <br /> ComP6y II Com an <br /> Time '� 1` Date Tiimep y Date Client Phone <br /> SEOM CUSTIFEC FAV Z= <br /> 1, Date �_. / p Pagebof? <br /> 1 0 <br />