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IIIIIIIIIII� Illlllllllllli Illi• Illi• Illi• Illll• IIII- xU­EST <br /> AnON NALY ctoro SIS AND Reference Document No. <br /> 3044: <br /> COUO ZAMN CHAIN OF CUSTODY RECORD* Page 1 of <br /> Project Name/No. <br /> 1 � t--�4 LL-U E.oaSamples Shipment Date 7 �3 y Bill 5 <br /> Sample Team Members 2 J .. to: <br /> .. Lab Destination.8 Q <br /> Profit Center No. s aS'I Lab.Contact Ito <br /> Project Manager-4 <br /> Project Contact/Phone _i2 yC S a 1 a <br /> Purchase Order No. Report to: <br /> Carrier/Waybill No.13 <br /> Required Report Date <br /> Sample 14 sample 15 Date/Time 16 Containers <br /> � Com,- ' <br /> I, sam�pl 1Number Dssci on Collected P0r:e. 9 Aequeeted Testing 20Volume eer, °Condition on 21 <br /> - — Disposal <br /> 2 <br /> o►' 1ar� . ram Receipt Record No. <br /> Di37p <br /> r <br /> 3v <br /> Or3� y� r► +�� C�Fd�,. 4 � _ G � <br /> r C) 1 r <br /> 1319 1. t I/ <br /> Np <br /> Ll <br /> Ile Tim M= <br /> p1 3► �t ,�, -a,. <br /> /� • Gtr' � .+ �' <br /> ,. L <br /> r r MSI <br /> G �-a1 -�'I <br /> GrownA— RN92NI <br /> A.10 <br /> N <br /> -Special Instructions: 23 <br /> Possible Hra�d Identification: 24 <br /> NanfiazardY� Flammable [„� Skin Irritant Sample Disposal: 25 <br /> �I Poison 8 I�j kJnknown IJ Return to Client FJDisby Lab Archive <br /> Turnaro Time Required: 26 aC Leel:27 posal (mos.) <br /> Normal U RushrJ Lijlil.i <br /> Project.Specific (s ec' p <br /> 1. Relinquished by 28 _ � � Date: -A t - <br /> (&gnabxv/affikaia,i rate: 1111P 11,1. Received by 28 Date: <br /> [�/nrfivatii <br /> 2. Relinquished by Date: Time: <br /> (5 2. Received by <br /> ignewre/Affiliation} , <br /> Time: isimtu a/Amiation) —r Date: cl, _0 3 <br /> 3. Relinquished by' Date: Time: <br /> (3ignaUn/Affikaaon) 3. Date: <br /> Received by <br /> ' -11216L <br /> Time: isgn a/aaeao,i <br /> Comments:29 Time. <br /> � i <br />