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INTERNATIONAL <br /> TECHNOLOGY R/A Control No. <br /> CORPORATION CHAIN-OF-CUSTODY RECORD <br /> C/C Control No. 17 -10 5 8 <br /> PROJECT NAME/NUMBER LAB DESTINATION �- <br /> SAMPLE TEAM MEMBERS CARRIER/WAYBILL NO. <br /> [:Sample Sample Date and Time Sample Container Condition on Receipt Disposal <br /> Number Location and Description Collected Type Type (Name and Date) Record No. <br /> Special instructions: <br /> J'Possible Sample Hazards: <br /> SIGNATURES: (Name, Company, Date and Time) <br /> :w <br /> 1. Relinquished By: l eiinquished By: <br /> Received By: �. �: 2 Received by: <br /> 2. Relinquished By: ! 4. Relinquished By: <br /> Received By: Received By: <br /> WHITE-To accompany samples <br /> YELLOW-Field copy <br />