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INTERNATIONAL / <br /> ANALYSIS REQUEST AND Reference Document No 3 3 7 9 5 q , <br /> col:OLOrmyr CHAIN OF CUSTODY RECORD* Page -125-1 of <br /> z 3 <br /> Project Name/No 1-Fkc FE[1--moo Samples Shipment Date 7'�Cx D UP Iz-� BIII to 5 --T-� C4IZP <br /> Sample Team Members 2 � '�'�� Lab Destination 8 �'�� "�_� -J�E ��� �1)crr, ey <br /> p _ ri i4 r�i�u�z I C11 9 <br /> Profit Center No 3 1 _ Lab Contact 9 <br /> Project ManagerProject Contact/Phone 12 t�+a� ��-9Id0 10 i_`[- Co rip <br /> Report to <br /> Purchase Order No 6 Carrier/Waybill No 13 <br /> Required Report Date 11 t 2-Z8 .Cil _ ` • + - _ T <br /> Sample 14 Sample 15 Date/Time 16 Contained samplel Pro 19 Requested Testing 20 Condition on 21 Disposal 22 <br /> -,1 Number DescmpbonjM Colleatsd TWO Volutt <br /> rvatnre ram RecelRetard 111110 <br /> [ <br /> 12 I2.cf I ' kd'j C,rznoor)wgm2Q 174?V 152-5 tp Rr4 <br /> AA W <br /> 121Z91 IM VO,4 y0HL <br /> R►1� l �i l� " � y � r z i <br /> Special Instructions 23 <br /> Possible Hazard identification 24 Sample Disposal 25 <br /> Non-hazard----T-- Flammable J Skin Irritant J Poison B J Unknown J Return to Client J Disposal by Lab-;3— Archive (mos } <br /> Turnaround Time Required 26 QC L 27 <br /> Norma Rush J II J III J Project Specific (specify) <br /> 1 Relinquished b 28 Date z -r3-qi 1 Received by 2 Date /07,0-9 <br /> {Signature/AfEdiatm /=1n) Time [p y 1&gnawre/Affiliation) Time <br /> 2 Relinquished by ' Date /,.a A3-9/ 2 Receiv y Date /--�71&-� <br /> [SigOdLure/Affihation) Time / [Signawre/AffooaWn , Time <br /> 7 <br /> 3 Relinquishe"y Date 3 Received by Date <br /> 15+gnature/Affdiatinnl Time (Stgnawre/Affiliation[ Time <br /> Comments 29 <br />