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'�. .�---.,r.:--.: -.. �� _� -_ - '�.s. � " � �=t'-.xv.,rlisf +:.aTp�s�. �x���a-�.�+!,..r'-,i,,�'p�+.:�yL'4�.F1�^F'``.''�^'���-•�"°§^y aY.-+,-'�" __ - •.k7� ',�,�q� .. � �� <br /> TECHNOLOGY <br /> ...:NATIONAL ANALYSIS REjEST AND Reference Document No9 g <br /> :` � �7 3 <br /> CO ORATION CHAIN OF CUSTODY.RECORD* . Page 1 of <br /> Project Name/No. 1 ` � �N Samples Shipment©ate IF13 Bil! to: <br /> 5 zFcorms <br /> Sample Team Members.>. A1 ;' dab Destination's" <br /> -T I NEz c A o <br /> Proftt Center No. 3 �I I Lab Contacts = n <br /> Pro act Contact/Phone - }- 72 9 I '; r 3 <br /> Project Manager4 -i>. WL L[l llr 7r j 6 t2 i~sit� p x,10 Z T COK <br /> Report . m <br /> Purchase Order No.s _ Carrier/Waybill No: 13 (ate , �wc <br /> ... --7T-' -j N <br /> Required Report Date 11. )z za . ._ y 3 <br /> l 10 14 :14:411111 <br /> CD <br /> Sample 14 sample 15 Date/Time16 Container). sample) pre. 19 +ti Requested Testing 20 . Condition on 21 Disposal 22 <br /> Number Descri n Collected ; Volume servatiire ram ReceiptRecord No. <br /> I71791 Fes, F1cLD E�AmLe IZ17-11A010 <br /> VoA�= r'. yon. :%};c� rr�7-Ex J: <br /> _ -n <br /> 1-UH LAU <br /> 1, <br /> Uzi <br /> 4"Irf 0- <br /> s ^ <br /> G.F27CD <br /> cn <br /> CD <br /> Cr <br /> n <br /> Special Instructions: 23 rc <br /> o <br /> I` Possible Hazard Identification: 2aSample Disposal: 25 <br /> Non-hazards Flammable fJ ; Skin Irritant J Poison 13 J Unknown J Return to Client J Disposal by Lab.;--Y- Archive <br /> T-ur-nar-ou d:Time:Required: 26 DC Level:27 <br /> Normal Rush[J] r II J pi.J Project Specific (specify) ' <br /> 1. Relinquished by--2Q Date: t� 91 1. Received by 2 Date: / -10 <br /> (Signature/Affiliation) lnoTime: I a i1 a <br /> (Signature/Affiliation) <br /> _ Time: Js-,p <br /> 2. Relinquished by Date: P <br /> j 2.°Receiv Y. - Date: <br /> f t. <br /> (Signature/Affiliation) Time:. (Signature/A i tion) Time: <br /> 3. Relinquished by Date: 3. Received by Date: <br /> i (Si nature/Affiliation) <br />� a • - Time: (signature/Affiliation) Time: <br /> Comments:29 <br /> ¢ .. - MCR 3115!41 <br />