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VxOiii i i i iN = i ir = i o <br /> ANALYSIS EST nt 1NAL E <br /> TECHNOLOGY <br /> iz o �oN� � c CHAIN OF CUSTODY RECORD* Page 1 of <br /> - Ac.r�(-, <br /> Protect Name/No1 (�L C k b � Samples Shipment Date 7 Bill to 5 n <br /> Sample Team Members 2 Y� i`t L(� Lab Destination 8 1 TA M��''}L <br /> a <br /> Profit Center No 3 Lab Contact 9 <br /> Project Manager < < E r{ `� Project Contact/Phone 2 �� t c (}I��f~7 10 �' <br /> el to <br /> Purchase Order No 6 Carrier/Waybill No 13 � <br /> Required Report Date 11 • • <br /> Sample 14 Sample 15 Date/rImel6 Container1 Sarnple1 per" 19 Requested Testing 20 Condition on 21 Disposal 22 <br /> Number Desceh teen/T Collected T Volume servateve P ram Receipt Record No <br /> Skj- � - Z�z C-cit_ ZE3�`I �C"XZ�� _ ( t <br /> �'K <br /> Special Instructions 23 <br /> Possible Hazard Identification 24 Sample D[spospl 25 <br /> Non-hazard k>i Flammable J Skin Irritant J Poison B J Unknown 1-J Return to Clien J Disposal by Lab'J Archive_ (mos ) <br /> Turnaround Time Required 26 OC Level 27 <br /> Normal 2 Rush J 1 ,J II'_J III J Pro ect S ecifiq (spwft <br /> 1 Relinquished by 28 ,ll ,'} j Date = G t 5 1 Received by 28 / Date f l J <br /> (Signature/Aff11jaUon1 1i q� I , lam— Time t [Signature/Affr&aUan! f l �� 1{ -) Time <br /> 2 Relinquished by Date 2 Received by Date <br /> (Signature/AffilioucM Time (Signature/Aff lietaoril Time <br /> 3 Relinquished by Date 3 Received by Date <br /> (Signature/Affihatlon) Time [Signature/Affiliation] Time <br /> Comments 29 <br /> MCA 1115', <br />