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WATIONAL <br /> TECHNOLOGY ANALYSIS REet ST AND Reference Document <br /> ® <br /> ac CORPORATION CHAIN OF CUSTODY RECORD* Page 1 of I <br /> Mow(- ; <br /> LU Project Name/No 1 ka�c�cr� �- <br /> � S-mc -J�Samples Shipment Date ? ' /70/q ' <br /> Bill to 5 1-r <br /> Sample Team Members 2 G_ S I�u�. _ w {- Lab Destination's �qo3 i 4 f� t w3 _ o <br /> Profit Center No 3 35- 11 . - Lab Contact",,_o iwi.to: o <br /> Project Manager4 i iCu3;K Project Contact/Phone 12D. ,I[c A 7 L9,eo3 <br /> Report to Li <br /> 1° �� v3! r__ <br /> Purchase Order Nos Carrier/Waybill No.13 0,; <br /> Required Report Date "1 3 L--vs s • • + 3 <br /> N <br /> Sample 14 Sample 15 J Date/Time16 Contamerl1sample16 Pre` 19 Requested testing 20 Condibon on 21 Disposal 22 <br /> Number Description/Type Collected TWm IVolums servathre Progrenri Receipt Record No. <br /> o V tito A. I- %ISO <br /> - f li !Lr Ls, <br /> Ilk ` 6,4l6':1Ah2;1 <br /> t r n ANT <br /> 4 tl <br /> I {, " <br /> c 'w Z fo 1 C <br /> i <br /> 13s S iu �-r - - t '� « Pau III ifCDt <br /> o c L �...�3 1Soo G,y t _ t <br /> I u a r' c <br /> I � � <br /> nz L <br /> ec)al Instructions 23 _ ;�- - 3 3 <br /> Possible Hazard Identification. 24 _ _ pie Disposal, 25 - _ o <br /> Non-hazard FJ Flammable IJ r Skin Irritant nj Poison B ❑J Unknown Return to Client❑J � Disposal'by Lab❑.,� Archive (mos J <br /> M <br /> Turn arou [me Re uired 26LIJ �{�' L r n ;_ c, _, CU <br /> r <br /> Normal � Rush�J K " I l II -f!I �; Pro'ebt Specific (specify) <br /> 1 Relinquished by 28L rn Date o 4 z 1, Received by rl Date L- 3o-5 Z <br /> (Signature/Affillateon) ? Time [Signature/Affiliation) �' <br /> T Time' r gar? o <br /> 2 RelinquishedP J Date ___�-z-9 z _ 2 Received by �, Date 7-�_�� N <br /> [Stgnewre/Affiliation) (��¢� 11 r Time j D d o (Signature/Affilievon) <br /> line c 3 <br /> 3 Relinquished by Date 3 Received by f Date <br /> (Signeture/Affiliation) Time [Signewre/Affiliation] <br /> Time <br /> Comments 29 <br /> MCA 3115191 <br />