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rrrr r m r <br /> r� r rr rr rr r <br /> A't'tONAi. ANALYSIS REQUEST AND Reference Document No 3 <br /> TECHNOLOGY j U I l <br /> 0a <br /> cORPORAT10N CHAIN OF CUSTODY RECORD* Page I of I <br /> �f}C�i FSG ,g�cL K <br /> Project Name/No9p ��, y _ Samples Shipment Date ? -2-t'-q3 Bili to 5 _/T__ 0-0/1VSample Team Members ? <br /> Lab D <br /> Y" <br /> Destination s / /�wa,CE <br /> Profit Center No s Lab Contact 9 (! . S rAAX— <br /> Project Manager 5 ypNV-`y GFe&5 Project Contact/Phone 12 <br /> Purchase Order No B 13 - Report to 1a T an" <br /> Carrier/Waybill No <br /> Required Report Date 11 A e 7Z 0) <br /> z, <br /> Sample 14 Sample 15 Date/Time 16 Container) Sample <br /> z cis <br /> , Pre. 12Q 2t <br /> Disposal <br /> 22Number Requested Testing Condition on <br /> Collected ene Program Receipt Record NoType olume <br /> i <br /> 66 <br /> Z-7- or PH-�1,574X <br /> o <br /> 58_6 15 l0FD <br /> O <br /> ID <br /> W- �lzaUNDwr�T o0 1 pa, Ttx <br /> y <br /> CD <br /> rD <br /> EDfn <br /> a <br /> I <br /> Cl <br /> Special Instructions 23 <br /> Possible Hazard Identification 24Sample Disposal 25 a <br /> Non-hazard C,-'Flammable 'J Skin Irritant J Poison B J Unknown J Return to Client J Disposal by Lab U"" Archive [mos ) <br /> Turnaround Time Required 26DC I evel 27 <br /> Normal J Rush J Project Spec eci ), 5 <br /> N <br /> 1 Relinquished b 28 R <br /> q Y Date t��' T? 1 Received by 28 pate z 7� <br /> (Signature/AheGun) Z- rr,0 5ff <br /> Time 15ignature/AffdaationlTime R <br /> p <br /> 2 Relinquished by Date 2 Received by Date Ln <br /> frAgnature/Aff habon) <br /> Time (5ignawre/Afiiliauon) Time <br /> 3 Relinquished by Date 3 Received by Date <br /> (Signature/Affdu3Unn) Time (Signnture/Affdiaunnj Time <br /> Comments 29 <br /> MCA 9/1 5 91 <br />