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Cham-of Custody Number: 3 98 <br /> SECQR Chain-of Custody Record <br /> Field Office 0277 eR6,cAo &2rr&�2 Additional documents are attached, and are a part of this RArd <br /> Address � 17_&Iddx- Zy 3/Op -- _ Job Name <br /> eg&'W-40 <:Ir�00cr - Location <br /> r <br />� Project#472.5eQA=C _Task#� <br /> Analysis Request <br /> Project Manager/-T 'M Ade4&e'r1cant"_ <br /> laboratory l�rf-Y p r <br /> Tumaround Time _ I -� 'w a � <br /> P n 8� c5'� m <br /> m <br /> � m U I 4E U o <br /> Sampler's NameO44" 1.0 <br /> ?og� UE bc <br /> m o <br /> Samplers Signatu m N $g g a�NQp� J a <br /> __- � 2 r ie3 m Wa O J <br /> Sam ID Date Time Matrix z �� �w a z m o a a 2 Instructions Z <br /> w _oZ <br /> -03 <br /> -06 <br /> 11211 IV <br /> / <br /> d� rl <br /> Special Instructions/Comments Relinquished by Received by Sam a Receipt <br /> AWY-1*3 Sign Sign Total no of containers <br /> Pnn Print Chain of custody seals <br /> Company CompRecd in good condibon/cold <br /> M(pD Time � � Date d0 Ti an Date Conforms to record <br /> Relinquished by Received by Client <br /> Sign Sign <br /> Print Pnnt Client Contact <br /> Compan Company_ki�A41!1 ra f <br /> Ti Date Timeliys Date//!703 <br /> Client Phone <br /> sEWA CUST c wr ZW <br /> Date I I Page of _ -_ <br />