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_ .;NATIONAL <br /> TECHNOLOGY ANALYSIS RE .,LEST AND Reference Document No:` � 7 95 3 <br /> TECHNOLOGY <br /> CORPORATION 19o9i�, CHAIN OF CUSTODY.RECORD* Page 1 of <br /> 1 <br /> Project'Name/No. i�►�f Samples Shipment Date Bill to:5 Z7 Gor V-;:- =r <br /> Sample Team Members 2 �L i-�acr ica �J� io <br /> Lab Destination <br /> Profit Center Nn. s LI I- _ 1. s ';; r--[ 1]rCrT[+)Ec CW 9�l j <br /> Lab Contactc <br /> Project Manager4 �. ictsE)L� �r Project Contact/P 12 6i( `=� <br /> hone -72 I� <br /> Report tail° r Comer=. <br /> Purchase Order No: �- Carrier/Waybill No: s -� (atenFc- <br /> v� <br /> Required Report bate-" <br /> N <br /> • o <br /> Sample 14 Sample 15 Date/Time 16 Contained. Sample' Pre. 19 20 <br /> Requested Testing Condition on 2' Disposal 22 <br /> Number Descri n Collected a Volume serWathm ram .. Rwmi Record No. <br /> 17 1-29 I F� F iCl� L�kAmLC IZlzgr to la 1/0A`� ;, q0 : ;FjcL .: = 'T EX m. x: <br /> ,f' CD <br /> PUN LAtJ In <br /> 7a Arn) <br /> r t:•. D <br /> w Ilk _rF1 11 <br /> D/ <br /> . .. <br /> G20uarrwLIZ <br /> Cr <br /> T", m <br /> i o <br />� <br /> Special Instructions: 23 0 <br /> 0 <br /> Possible Hazard Identification: 24 Sample Disposal: 25 <br /> Non-hazards Flammable Skin Irritant CJ Poison 8 ❑ Un'known <br /> J Return to Client U1 Disposal by Leh Archive (mos.) Cn <br /> Turnarou d Time Required: 26 DC Leel: 27 <br /> Norm aJ ._ Rush CJ �_...._ _ _ t _ ._� „_. w. <br /> 1 ILLJ Ili.�j Pro-46t Specific (s ec' )- <br /> 1. Relinquished by-2 Date: I f 91 'I. Received b 2 _ D <br /> (Signature/Affiliation) .� }�� y Date: 'll3 c <br /> 1 .0� Time: 10 I J [Signature/Affiliation) - <br /> Time: <br /> A,5-0 �*- <br />,. o <br /> 2. Relinquished by Date: 2. Receiv _ <br /> {Signature/Affiliation) y. ,. Date: <br /> Time: (Signawre/A tian) <br /> 3. Relinquished by Date: Time," <br /> i (signature/Affiliation) 3. Received by Date: <br /> Time: (Signature/Affiliation) <br /> Time: <br /> Comments:2s <br /> t MCA 3115M <br /> r <br />