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�971V6, �i6 <br /> WESTONI,nefyticaUs®on1 <br /> ly Custody Transfer Record/Lab Work Request <br /> ReirigeratonP <br /> Client k #TYFe Container tivESAnalytics <br /> Use On!TON <br /> work Order _ -�,, „� ,. YoTunro Samples Were: <br /> EA <br /> ~ i .., <br /> ' ' 1 Shipped or Hand <br /> Dole Recd.�� '� —Date Dae �es@rvativs - -- -- -- -- <br /> - NOTDeliES:ed <br /> RFW Contact i: NOTES_ <br /> ClientContbcVPhone REQUANALYESTED <br /> -}.• RERUESTED <br /> � <br /> 2 Ambient or Chilled..i A Lob <br /> only Client 1DIDescription Matrix Date NOTES: <br /> Collected <br /> k ' 3 Received Broken/ <br /> r- �, y! - ;,. Leaking(Improperly <br /> 1 > 5 i r .: Sealed) <br /> NOTES: N <br /> H 4 Properly Preserved <br /> N <br /> NOTES: <br /> 5 Received Wilhin <br /> yQ, Holding Times <br /> y� Y N <br /> NOTES: <br /> COC Tape Was: <br /> {fj 1 Present onOutor <br /> Package y N <br /> 2 Unbroken on Outer <br /> __ .- Pactcage Y N <br /> Metrb1 w-water a5-Arumaotlde 3 PresentpnSampla <br /> S-sora p_ DL drum Llqu Special Instructions: j- a <br /> SE-SWiment A-it N <br /> FidO Unbroken on Sample <br /> 4t)•Sand F- shOr a <br /> 4 <br /> W!-WIPO X-Oth , _ NOTES: Y N <br /> iterrvReeson Re!r. uTslted b er�y b ------------ <br /> ata t Tima di shed b R ved b CDC Record Was: <br /> I ).- t! Date Time <br /> -. 1 Present Upon Recelpt <br /> of Samples Y N <br /> Discrepancies Between <br /> Sample Labels and CDC - <br /> Record? Y N <br /> NOTES: <br /> RFW 21-21-MljA.7188 <br /> 7-115 <br />