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NA�o'� r w r ■r r r �r wN 0�� <br /> ANALYSIS REST AND <br /> Ti�CM01.0 r Reference Document o <br /> CORPORATION J cel/fr CHAIN OF CUSTODY RECORD* Page 1 of <br /> Project Name/No 0-Er-9) _ Samples Shipment Date 7 r7 4.f 1,X x l a, 1 8111 to 5 ZL_ <br /> Sample Team Members 2 -I t( , ��—__ Lab Destination 8 �G�... ' +, 1�•��-/ y _ _ 1 <br /> Profit Center No 3 � _L �- _ Lab Contact 9 -�--�� _ — ° <br /> `2�y r <br /> r <br /> Project Manager4 Project Contact/Phone 12�r� - - -- <br /> Report to 10 >/ • i <br /> Purchase Order No -�-r G 13 _____ o <br /> — -�� Carrier/Waybill No -- <br /> Required Report Date -- <br /> t <br /> Sample 14 Sample 15 Onte/Time 16 Container) mplelf pre. 19 Requested Testing 20 Condition on 21 Disposal 22 <br /> Number Description/TypeCollected T Volume sarmativa rem Receipt Record No. <br /> la,a I ?.a r,k� r' ��r -a3 Q 1, I(r) POAJ-Nes r rB <br /> Own <br /> " <br /> x <br /> � ' till <br /> r n f a <br /> r <br /> � n <br /> r <br /> O <br /> Special Instructions 23 2 <br /> Possible Hazard Identification 24 Sample Disposal 25 0 <br /> Non-hazard*J Flammable Skin IrritantyJ Poison 8 J Unknown 52 Return to Client Disposal by LabL.�! Archive__ _ _� <br /> Turnaround Time Required 26 DC Level 27 (mos ) n <br /> Normal K� Rushy fu II UJI III [:) Project S eq c [s ec ) <br /> I Relinquished by 28 Date 0 1 Received by 28 Date <br /> (Signature/Affilralion) j( Time f Z ] fSignewre/AffillaWn) / l,ti (1 L �� Time ,# <br /> 12gnRelingfiuued by _Date 2 Received byoni Date <br /> Time (Signewm/Affshatmn) Time <br /> 3 Relinquished by Date _ 3 Received by Date _ <br /> 19gnawre/Affiliauoni ti Time ftnawre/Affillatoni Time <br /> Comments 29 <br /> MCA 3115191 <br />