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OWE— <br /> I NATIONAL ANALYSIS RE EST AND Reference Document NO I <br /> ® <br /> CORPORATION CHAIN OF CUSTODY RECORD* Page 1 of I <br /> CORPORATION g <br /> Project Name/No �a�c N,--L s rc r_� T• Samples Shipment Date Bill toCD <br /> 5 x <br /> Sample Team Members ? �����ln+� ti Lab Destination e ��ta4 ��� <br /> Profit Center No 3 'a c 1 I _ Lab Contact 9 C A <br /> 4 1 i�r_1i3,I- 2 Project Contact/Phone 12 ,� ' ' ` Report t0 l ! 1"� m <br /> Project Manager_ �� ] p 10 � <br /> Purchase Order Nos Carrier/Waybill No �,� &j 1,� I , 't <br /> M <br /> Required Report Date 1' 3 L v s _ _ 3 <br /> N <br /> Sample 4 Sample )5 Date/Time sample Pre- 9Requested Testing �� Condition on Disposal 22Number Descri on/T a CollectVolume servative Progranii Receipt Record No <br /> 21 <br /> a <br /> r <br /> r�r 1 <br /> t 'r rU i S INC <br /> cn <br /> A Cr <br /> d <br /> 0 <br /> 0 <br /> Special Instructions 23 <br /> Possible Hazard Identification 24 Sample Disposal 25 <br /> Non-hazard J Flammable J Skin Irritant J Poison B J Unknown d'' Return to Client J Disposal by Lab J Archive (mos ] 0 <br /> Turnaround Time Re uired 26 QC Lavel 27 <br /> Normal Rush J I J II J III J Project Specific (specify) <br /> in <br /> 1 Relinquished by 28 Date i 1 Received by 28 n Date C <br /> (Signature/Affiliation) ? <br /> Time �C�� (Signature/Affritatlon) J r I i Time R <br /> o <br /> 2 Relinquished b Date 2 Received by ! in Date N <br /> (Signature/Affilotlon) { ) f {„Y I S Time 1 I�r, )Signature/Affiliation) r i Time <br /> 3 Relinquished Iby ! Date 3 Received by Date <br /> iStgnature/Affiliation) r <br /> _ Time (Signature/Affiliation) Time <br /> Comments 29 <br /> W A 1 1',91 <br />