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0 3 Chain-of Custody Number <br /> SECOR Chain-of Custody Record <br /> '] <br /> Field Office Additional documents are attached, and re a part of this Re`i�brd <br /> � + <br /> Address 0 Job Name <br /> U J C, Location t,Z.1;<R6 <br /> i <br /> 1 �7��� 0,bf7 Analysis Request <br /> Project# "'Task# <br /> Project Managor <br /> Laboratory U= c�Q N <br /> N <br /> Turnaround Time Z h a m a mo m U, µ <br /> � ohm <br /> L 2 L i8 `° , . v <br /> q 02 m U 3 <br /> o mC7 y ..C7 <br /> Sampler's Name i �1 m E a E 00 m oa°r m M <br /> `� ,� �y0 dN d0 ?N VO J — 0 <br /> Sampler's Signature D T =T Y E N o E N w -ca NCDM co —co o m a _ Comments/ 7 <br /> Sample ID Date Time Matrix <br /> z <br /> 0.0 ro � ¢r (0 Z rD u]"W a( r� a` r .�,� Instructions Z <br /> Special Instructions/Comments Relinq ahe Received by Sample Receipt <br /> Sign Sign Total no of containers <br /> Print Print Chain of custody seals <br /> Company PCZ Company Rec'd in good condition/cold <br /> Time JLJ3Q Date ' Time Date Conforms to record <br /> Vn4ti1 Relinquis ed b I a Received by Client <br /> �- Sign ,A- Sign <br /> Vi k&k, Pant ' Print Client Contact <br /> Com any Company <br /> Time Dated 0�'a Time Date CI►ent Phone _ <br /> SECOR CUSTREC Rev 2199 <br /> Date ` / I d ` Page of <br />