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IIIIIIIIIN n�r M M = IIS i M M M ! = M <br /> [FiATTONAL ANALYSIS REIT ST AND Reference Document N 3 wo, 5007 <br /> T£CHNOLOGY <br /> COMMA N F ���� •05 CHAIN OF CUSTODY RECORD* Page 'I of <br /> Project Name/No �l� 5i.=14. OP2M?—Sampies Shipment Date ?— -7- ICA,�)9-7f> _ B[II to 5__r,'l <br /> y X35 "`7 }-lt�s� <br /> Sample Team Members? Lab Destination $ ''i` --- M^eTi Z <br /> Profit Center No 3 _� Lab Contacts <br /> Project Manager! Project Contact/Phone �2 '��� Report to 10 'fl ��l __— <br /> Purchase Order No 6' z-�-' + ��- Carrier/Way bill No f3 _— f <br /> — N <br /> Required Report Date 11 ---- <br /> -- ro <br /> Semple 14 Sample 15 Date/Time16 Container Samplel pre. 19 Requested Testing 20 Condition an 21 Disposal 22 <br /> Number Description/Type Collected Type Volume servatave Program Rerer t Record No <br /> -n <br /> CL <br /> , reg i.+cr ptl F LD <br /> fPpr-e <br /> w a Y In <br /> 11 <br /> n <br /> 0 <br /> 0 <br /> I <br /> Special Instructions 23 3 <br /> Passible Hazwd Identification 24 Sample Disposal 25 <br /> Non-hazards Flammable 1,J Skin Irritant � ;� Poison B iJ Unknown IJ Return to Client IJ Disposal by Labe Archive (mos ) w <br /> TurnarouN Time Required 2EDvel 27 v <br /> j Normal J Rush J J III J Iii �. Project S ecifi (specify), - - ---- _ - - - _- -- N <br /> 1 Relinquished bsr Date -71 t ce 1 Received by 28 Date '71 Cv ti <br /> [sig wUre/AlShshon) Time S� ftnou" Aflfihewn) Time jy��,b <br /> cow0 <br /> 2 Relinquished by Date _ ____ 2 Received by Date _ _ - <br /> [s+gnewm/Afflhshon) Time igen /AHdistm) _ <br /> Time <br /> 3 Relinquished by Date _ 3 Received by Date <br /> [SrgnaWm/Afiihet+onl Time - T -- ftnstum/Attiliewn] <br /> Time <br /> Comments 29 <br /> MCA 311"1 <br />