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ATIONAL [ AN <br /> TECHNOLOGY ALYSIS RE EST AND Reference Document No VW00 <br /> CORPORATION CHAIN OF CUSTODY RECORD*i- Pagel of <br /> Project Name NO.1 F yr� Ck1 �9P7/G ;°r n ^ Tl�/�' E7� � e 5 <br /> ! / Samples Shipment Date ' Bdl to �� � �'/a��oc' Io <br /> Sample Team Members 2 -eA^ 1 ' ` : (j ti Lab Destination <br /> fit Center No 3 � l l ` ' — <br /> Pro <br /> -- - �r Lab Contact r n <br /> Project Manager'4�:L7 L9 6ik,4 �e � Project Contact/Phone 12- rd� l�rx� (gym (�ro� ° <br /> 3 <br /> r <br /> Report to 1 _ � v�} m <br /> Purchase Order No ,6, �G1�c1�� �_ ,-; Carrier/Waybill No�13 -�-=�~--�A <br /> Required Report Date 11iA� ? = s 3 <br /> CD <br /> Sample 14 Sample 15 Dew/Time 16 Containers Sample! fire-f 19 Requested Tesdng 20 ' _CQndrtion on 21 Disposal 22 <br /> Number Descri n Colfected'� Volume ; sar�eative , ram ReceiptRecord No. <br /> j1/Q yLc l J"y' Cif <br /> /.�1k 7�. rIQ4j � AIO !"jh �G a+r^_I�•L/ciLUCJI�I'!� � � � rj 3 r, fx <br /> let <br /> CL <br /> 13 _ c DLPOC UtMLT <br /> - <br /> - .0 t C ''T . -C <br /> LR t N " - .f N •'• Q, J .rL_7 C_ fi 0�' C� (: J w C� C � L� <br /> r' Q < <, <br /> cv c = �' u n ? w �, co w a . o y -- E 9ry f x. <br /> c <br /> ns 7. <br /> ' n CT } C' F= Qt r. r ry '� 4 - L ('1,f_ 0, ffl »- >= u � r J LLON <br /> r v <br /> CF li '� 1 i• ?T h 7�" �� p _ n Q) r <br /> ^ n r n ^ r ( <br /> MW MW MW TOM a MJ <br /> +N c ,} ' „ " <br /> O R 9 6 N L r� � � . L7 cr t W <br /> r _ <br /> ti _ <br /> r '} J sni, � C `u rr^f `. � n ^, � " u` <br /> -T <br /> Special Instructions. 23IL <br /> .C, -��L9 <br /> Possible Hazard Identification 24 C. 7, Sample Disposal. 25 f, ' r r _ <br /> Non-hazard LQ Flammable 1A Skin Irritant 11 ; Polson 8 QJ C. <br /> Unknown T N <br /> r �� Return W Client� - Disposal by Lab ' Archive (mos ) ° <br /> Turnaround Time Required 26 u DC Level#? „ - <br /> Normal Rush C� _ ° = �„ > n, o , c 1 " f, - = 7 p1 <br /> r fl III r Project S eci r,(specify).) I r _ <br /> 5 <br /> 1 Relinquished _Date `" -�i� 1 'Received by 28 I . µm, Date, <br /> '' 7 G <br /> (signature/Affil an) 7 Time :DJ m (signeture/Amewn] � : 1•� ;-" Time <br /> 2 Relinquished by Date 2 ,Received by, r; Date N <br /> (Sgneture/Affifiadon) Time 'gTime. <br /> 3 Relinquished by r t Date - 3. Received by I <br /> (Signature/Affibetlon) \ - Date <br /> ri Time (Signature/Affillauon] - i' <br /> r <br /> r ,Time;, <br /> Comments 29 _ s 0, L <br /> r ?) r n <br /> r u} f <br /> S T [ <br /> MCA 3115!91 <br />