Laserfiche WebLink
r = r = �r = r = r M = r r 0IT4 <br /> i e:RNA'i'IONAL ANALYSIS RE EST AND Reference Document <br /> COR ORAUCI r CHAIN OF CUSTODY RECORD* Page 1 of Z <br /> PACIFIC eEe.L <br /> Project Name/No 1 ?0 V6 if Samples Shipment Date '�—y 3 Bill to 5 <br /> Sample Team Members 2 j l L .t , %,A r/ir—, 4 Lab Destination 8 7- T HOMLE LA <br /> Profit Center No 3 Lab Contact 9 r �f��"� - C; <br /> Project Manager4_C�EL S __ Project Contact/PhoneeRort to 10 ( T '1 <br /> Purchase Order Nos Carrier/Waybill No 13 <br /> Required Report Date 11 _ a - :J4 0 C F r <br /> Sample 14 Sample 15 Oate�me 16 Containers Samples pre- 19 Requested Testing 20 Condition an 21 Disposal 22 <br /> Number Oeseri tion/T Collected T Volume servatnie Program Receipt Record No. <br /> 0l 2 �� . 3� �r £ss lk6x - 137 x { x <br /> Ft <br /> 5a—�{ ' t- <br /> (I <br /> U <br /> tl <br /> 41. Y5 It <br /> Special Instructions 23 <br /> Possible Hazard Identification 24 Sample Disposal 25 <br /> Non-hazard 6'*'� Flammable 'J Skin Irritant 'J Poison B 'J Unknown J Return to Client IJ Disposal by Lab`� Archive (mos ) <br /> { <br /> Turnaround Time Required 26 QClevel 27 <br /> Normal J Rush J I II'J III 1J Project Specific (s ecr ] <br /> 1 Relinquished by 2SjA <br /> Date Z A M IU 1 S 1 Received by 28 ate <br /> (Signature/Affiliation) Time (Signature/Affiliation) IAA/Time <br /> 2 Relinquished by Date 2 Received by Date <br /> (signature/Affiliation) Time (Signature/Affiliation) Time <br /> 3 Relinquished by Date 3 Received by Date <br /> (Signature/Affiliation) Time IS+gnature/Affiliation) Time <br /> Comments 29 <br /> MCA art 5 � <br />