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= IN*= = = i = = = w ! <br /> INTERNATIONAL ANALYSIS REQUEST AND Reference Document * 328622 <br /> CORPORATION CHAIN OF CUSTODY RECORD* Page 1 of <br /> Project Name/No 1 _A:&u, _050� Samples Shipment Date 7-r-WJ X9-25E:�' 9-76 4-7- Ball to 5 <br /> Sample Team Members _ �_ _ Lab Destination �� C�1f1�1ZDN�tt�lA9� � � � � � - -- <br /> Profit Center No 3_ 2271�___-- - Lab Contact o <br /> 3 <br /> Project Manager4_ S."I� T Project Contact/Phone �� ��ioJ372 5? � 10 / a _ _ <br /> Report to _ III <br /> Purchase Order No 6 T03/T88 _ Carrier/Waybill No 13 <br /> Required Report Date 11 - _ a -� T <br /> Ln <br /> Sample f4 Sample 1$ Date�me 4 Containers Sample( Pro- 19 Requested Testing 2Q Condition on �� Disposal 22 <br /> Number Qescrfption/T Collected T e Volume senratn►e P ram ReceiptRecord No <br /> ra <br /> Z CIO/ 6,&X-7 V-r r,l5 boot $,� 60V 40 e cV00~l AZT (..� C <br /> Z2 ��50 T <br /> a <br /> rZSo1 4 tl - a <br /> +"* <br /> GQ3�ZC6.�- <br /> STs�v r�jrA n ^ <br /> i 3 T <br /> U1 <br /> M <br /> I Q <br /> Df <br /> C7 <br /> v <br /> C <br /> 0 <br /> 7 <br /> Special Instructions 23 3 <br /> Possible Hazard Identification 24 Sample Disposal 25 ° <br /> Nan-hazard✓f Flammable J Skin Irritant IJ Poison B I J Unknown Qj Return to Client 1_J, Disposal by Labe Archive_ (mos I o <br /> Turrlaroupd Time Required 26 DC Level 27 v <br /> Norma l-J Rush J I j II IJ III IBJ Project Specific (specify). <br /> 1 Relinquished by Date `�- _ 1 Received by 28 _ Date_p�j Sof y�- <br /> (Signature/Affiliation) I Time )Signature/Affiliation) Cl,� Time ,30 rn n <br /> a <br /> 2 Relinquished by Date 2 Received by Date <br /> (Signature/Affshation) Time (Signatime/Affiliation) Time <br /> 3 Relinquished by Date _ T 3 Received by Date <br /> (Signature/Affiliation] Time (Signature/Affiliation) Time <br /> Comments 29 <br /> MCA 3/15mi <br />