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<r-- . .. � .:� �. _ .r— ar.--'ar t'�e r-►a..m+.r��14.4rsr----mac <br /> Ile <br /> Tr <br /> Ec�naor o A ANALYSIS REQUEST AND Reference Document No '717955 <br /> CORPORATION r CHAIN OF CUSTODY RECORD* - Page–Tiy — <br /> tl C Eta ' �Or-6e'00 n � 7J � ' �? (?=I� 5 Of � = r = to <br /> Project Name/Nor Samples Shipment Date �: �� �U Bi11 to T ' ��' <br /> .I <br /> f > F, 'SC��€ —�- `~ "�--Ac NC Co_, 4VZ—i <br /> Sample Team Membersr2 �- � ' ' y z- _' ;;Lab Destination sFlN _ `�A <br /> _ ' - t _ � � f"lAf2Tlrylr� i CA <br /> Profit Center No ''s`!� _ -a `' c+ ' Lab Contact„� >;'. 'ACS _ f 0 <br /> Ctr fi5'7 CI <br /> Project Manages K�Le —Tv?, - Project Contact/Phone112 C.�6)-�E��foo = 10 - <br /> T_m Report to,' <br /> Purchase Order No 6 ti Carrler,"Waybill No,13, °' �, F ��� (� �-r-E v IW, <br /> Required Report Date 1 <br /> Sample 14 r, Semple 5 Date/Time 1 B Cantainerl Sample 1 y,Pre•,19 Requested Testing 20_ S Condition an 21 Disposal 22 N <br /> Number Dascr� n Collected , T n Volume serwatfus t,l ram = t Rete ` Record No. <br /> r� <br /> I�Um ALS <br /> —b, <br /> 11 <br /> U to r C) <br /> I t �� .�/f S tti '� t1 , f� ��/ r t� P Y� r•- C C> IT ' <br /> T <br /> ►fi r -0 Yr r� % _ } 3 Jl�_ t? r c C3An <br /> a] -Y lJ N a7-� i{ Cl '7 03 r 't` LI ;,.«. �i rp rr' <br /> C O Cl m m T C� r, i7 ' C_ r+ r n iq it tl) f+-_ C '� ir; n i i v <br /> MW Tr9w no mmar VA a M <br /> O 1 f <br /> Cr <br /> _ f x <br /> p <br /> r � <br /> Special Instructions 23 r u3 U <br /> 1 n, U ei ft 'J' ,� /r. ?r r'^ all <br /> Possible Hazard Identification 24 r Sample Disposal 25 r - J f o <br /> Non-hazards Flammable J Skih Irritant E t Poison B [J'7' <br /> Unkn�nrn Return to Client EJ r Disposal by Labs” Archive [mos j , <br /> Turnaround Time Required 2s ��, OC Level 27 z ;, „ { > 1 <br /> NormaL� Rush�J - r r - Ir� II 111 = Pro act S ecific ( ec ):' = r s N <br /> 1 Relinquished b 28 �, Date _ i�� I,;, `i i T 1 Received by „�, f r ,Date <br /> (5tgnature/Affiliation} " — = Time ` p , f� (Stgnsture/Affitishan) Time <br /> 2 Relinquished by -r Date _ _ 2. Recely y , , Date N <br /> (Signature/Affihetion) Time (Signawr'e/A von} Time <br /> 3 Relinquished by 3 3 DateT' _ 3 Received by ; , , Date <br /> (signature/Affihatmn) 1 a a Time,-- (Signature/Affiliation) cr Cn a v s <br /> Time, <br /> Comments <br /> - r5 <br /> AICA 3!15191 <br />