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15 = r = 0 JPI"!b <br /> A'TIONAL ANALYSIS RE EST AND Reference Document <br /> TECHNOLOGY <br /> PAe1FIC' 9t CHAIN OF CUSTODY RECORD* Page 1 of � <br /> 6 L <br /> Project Name/No 1 / 9 0 yI6 �f Samples Shipment Date 7 -`l`T 3 Bill to 5 C'010-P n <br /> Sample Team Members 2 i`'!.HIAJ >K Lab Destination s -Fr P06�LE L1Y - <br /> 0 <br /> Profit Center No 3 _ Lab Contact 9 <br /> Project Manager Sy1)pe>1 5 Project Contact/Phone 12 10 fid '/' <br /> Report to 1 T- t <br /> Purchase Order Nos Carrier/Waybill No 13 <br /> Required Report Date 11 _ /(-f T 1 <br /> 71Sample18 <br /> z�tSample 14 Sample Date�me Copre- 1 Requested Testing �� Cond�t�on on 21 Disposai 22 <br /> Number Descry on/T Collected servative p ram Recei t Record No <br /> aot �— ly�v3� -- untie- TPN-b/B tE )< <br /> { <br /> S8, 3.7- 2 <br /> JF3 - 3 _ J_ Z Ij Z l.5 rl it IF E X <br /> )) ` 1I 11 <br /> 5515- 3 _6_ Z / z , �-5 it <br /> 56 --3 .2- 2. , + 7' y5 Ir 11 f� <br /> Special Instructions 23 <br /> Possible Hazard Identification 24 Sample Disposal 25 <br /> Non hazard L1� Flammable J Skin Irritant �,J Polson B 'J Unknown _J Return to CIIenC'J Disposal by Lab' Archive _ _ (mos ) <br /> Turnaround Time Required 26 %�vel 27 <br /> Normal ,J Rush J II�J III J Project Specific [specify) <br /> 1 Relinquished by 21L' �Jl�� /,j�r Date �_� -�3 1 Received by 28 Date � . <br /> (signature/Affiliation) Time 13 /0- (5ignawre/Af giation) me <br /> i <br /> 2 Relinquished by Date 2 Received by Date <br /> (Signature/Affihegan) Time (Signature/AffihaUon) Time <br /> 3 Relinquished by Date 3 Received by Date <br /> (&gnature/Affilhawn) Time (Signature/Aff hewn) Time <br /> Comments 29 <br /> MCA 1159 <br />