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= r r = r M = <br /> r r = vmromltATIONAL ANALYSIS RE EST AND Reference Documen <br /> ® TECHNOLOGY CHAIN OF CUSTODY RECORD* Page 1 of --�— <br /> CORPORATION A( � <br /> WQ3 BILI to 5 R <br /> Project Name/No 1 ��( 1 �'� Samples Shipment Date - <br /> Sample Team Members 2 L Lt Lab Destination 8 T'��S WAAI -14ia <br /> Profit Center No 3 <br /> Lab Contacts ,-dile S�r�4/- <br /> Project Manager Project Contact/Phone 12 Report to 10 <br /> Purchase Order No 6 Carrier/Waybill No 13 _ - o <br /> Required Report Date 11 0 11 k + 1101:1- z <br /> +r <br /> 14 15 15 1 Sam le] Pre. 19 Requested Testan 20 Condon on 21 Disposal 22 <br /> Sample Sample Date/Time Container P q 9 <br /> Number Description/Type Collected Type Volume seruatnre p ram Receipt <br /> Record No <br /> _� � _Z ye,tQ �j 1(3� x�k•�►a. <br /> Jr <br /> I <br /> 1Zy <br /> 6- 7 ti'.c- <br /> 1Z 4t <br /> v <br /> Special Instructions 23 <br /> Possible Hazard Identification 24 Sample Disposal 25 <br /> Non-hazard J Flammable J Skin Irritant J Polson B J Unknown J Return to Client J Disposal by Lab`J Archive [mos ) <br /> Turnaround Time Required 25 DC Level 27 <br /> Normal J Rush J I I iJ 11 J III jJ Project 5 ecifi [s eci ) <br /> 1 Relinquished by 28 r Date Z 5-\q,5 1 Received by 2e Date _ <br /> (Signature/Affiliation) .-- � �L-- Time 1z: StD Tivl [Signature/Affiliat+nn) Time I <br /> 2 Relinquished by Date _ 2 Received by Date <br /> (Signature/Affiliation) Time (Signature/Affiliation) Time <br /> 3 Relinquished 6y Date 3 Received by Date <br /> (Signature/Affiliation[ Time (Signature/Affiliation) Time <br /> i <br /> Comments 29 <br /> MCA3t <br /> I <br />