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�. -1 <br /> 2T AT>iGY ANALYSIS RE EST AND Reference Document o 345091 <br /> CORPORATION CHAIN OF CUSTODY RECORD* Page 1 ofdE <br /> 1 <br /> Project Name/NoBill to 5�k >< KSam s�ocrcnl fes 5h) ment Date ?a �'2 <br /> 1 � p p f_ -. ---r' c <br /> Sample Team Members 2 i1 U'"- Lab Destination g ��t_ ��v!p 0AOA,1,.,.ITA `f� PAC ter G° o <br /> -r'' <br /> Profit Center No �s�I Lab Contacts <br /> Project Manager4 IL t3ti� . Project Contact/Phone 12 �u3i� ��Z 9/bo io <br /> Report to konj <br /> Purchase Order Nos Carrier/Waybill Na ,1 AMI)i 'k�LI J CED <br /> Required Report Date 11 3 CKs <br /> (D <br /> Sample i4 Sample 15 Date/Time16 Containers Samplel ,pis' 19 Requested Testing 20 Condition on 21 Disposal 22 N <br /> Number Description/TypeCollected Type Volume servatnre ram Recei t Record No,.-- <br /> j <br /> r,( 3a 4�- ••.� 65kc 0nl �2o y 34S az <br /> i a <br /> CL <br /> �, _0 _ <br /> e ) I Cl) <br /> m <br /> tr <br /> m <br /> n <br /> v p <br /> 0 <br /> Q <br /> Special Instructions 23 "�, 3-1 <br /> Possible Hazardjdentification 24 Sample Disposal 25 <br /> Non-hazard L Flammable 1 iJ Skin Irritant 1J Poison B LJ Unknown 1 I Return to GFlient CJ Disposal by LabQ-- Archive (mos ) on <br /> Turnaround Time Required 26 Q.C�Level 27 <br /> Normal 1-;�RushLj II 1.J III Project Specific (specify). <br /> 1 Relinquished by 28&,�� Date !j 3-/- z _ 1 Received by 28 Date _Uig(, _ <br /> (Signature/AffihaGon) ;.T Time y (Signawre/AffiliaGanl Time <br /> �l n <br /> 0 <br /> 2 Relinquished by Date 2 Received by Date N <br /> (Signature/Affiliation) Time (5ignature/Affihawnl <br /> Time <br /> 3 Relinquished by Date 3 Received by Date <br /> (Signawre/AffiGaGon) Time (Signature/Affibat4on) <br /> Time <br /> Comments 29 <br /> MCA 3115191 <br />