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Ann— <br /> �> > <br /> ERNATIONAL ANALYSIS R EST AND Reference Document [ I <br /> ® TECHNOLOGY <br /> CORPORATION CHAIN OF CUSTODY RECORD* Page 1 of f <br /> ! 75Project Name/No Samples Shipment Date B111 to <br /> n <br /> Sample Team Members 2 t ]'� `y `` Lab Destination a G L_ i �[< it c tir n nl] L11 A <br /> Profit Center No 3 `I Lab Contacts i <br /> Project Manager4 E' S . Project Contact/Phone 12 t. # f,i4,i i_ r�� ] ,f io 0--t_c ti� V c;rf: a <br /> Report to <br /> Purchase Order No Carrier/Waybill No 13 f , hj i�� 'L _ � 1 h r _ I-!( k/r- <br /> ric <br /> Required Report Date 11 ` ' t <br /> R <br /> u <br /> Sample 14 Sample t 5 Date�me 1 "Contamerple 1 pre. 19 Requested Testing 20 Condition on 21 Disposal 22 <br /> Number Descri tion/T a Collected me servative Program Receipt Record No <br /> n <br /> . _ ..� l),1. nit} �_(� � ��' � �� _- <br /> SL r I! tt/Ft j e7 r. : C/C? WS11 L —� Cl ( ^ <br /> 77 <br /> c <br /> N <br /> F a <br /> 9 <br /> C <br /> Special Instructions 23 _ <br /> Possible Hazar_d-ldent[fication 24 Sample Disposal 25 <br /> Non-hazard J"" Flammable J Skin Irritant J Poison 8 J unknown ,J Return to Ghent J Disposal by Lab-A-'Archive [mos J R <br /> Turnaround Time Required 26 OC Level 27 <br /> Normal J' Rush J 11 1 -J H J III J Project S ecific (s eci ) <br /> 1 Relinquished by 28 Date G / 1 Received by 28 c- Date <br /> [Signature/Affiliation] _ __ t Time �! , [Signature/Atfliawn] Time <br /> 2 Relinquished by Date 2 Received by Date U <br /> [Signature/Affiliation] Time [Signature/Affdiataon] Time <br /> 3 Relinquished by Date 3 Received by Date <br /> ]&gnature/Affil anon] Time (Signature/Affiliation) Time <br /> Comments 29 <br /> MCA 3115igf <br />