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sj,,7Ar1, A <br /> � M M M M M m ! i m m m <br /> TIONAL ANALYSIS R VEST AND Reference Document , !0�'O� CHAIN OF CUSTODY RECORD* Page 1 ofORPORATION r J r( <br /> Project Name/No %A r ' "' I`'^i Samples Shipment Date 7-1 f r _ r ! _ ! Bill to 5_ 1 t _ _ clCD <br /> Sample Team Members-_ < +t ^' ^' Lab Destination s rc c n 4'!/ C, V <br /> a <br /> Profit Center No 3 ` �'/ Lab Contact 9 - - - _ — _ _ p <br /> Project Manager t y K Grp- =�l� - Project Contact/Phone 12 io v <br /> - Report to —�� �- ,+ � a <br /> Purchase Order Nos Carrier/Waybill No 19 <br /> Required Report Date y 1 /�= / 9/ _ - - - -- - ro9 <br /> m <br /> Sample 14 Sample 15 Date/Tune 16 Container ei Pre- 19 Requested Testing 20 Condrtron on 21 Disposal 22 <br /> Number D n Collected T e Volume servatme Program Receipt Record No <br /> CD <br /> 'r W I; -�r rt,l r a: t/c"� VA irla2i r "Fr IF rLPJJ-1 <br /> I!_ <br /> ! ;!! � i ro <br /> a <br /> Li <br /> I <br /> Cr <br /> < ro <br /> ff <br /> n <br /> x <br /> E3f <br /> I , <br /> Special instructions 23 3 <br /> Possible Hazard Identification 24 Sample Disposal 25 ° <br /> Non-hazard--J Flammable 'J Skin Irritant J Poison B J Unknown J Return to Client'J Disposal by Lab J Archive [mos ) <br /> Turnaround Time Required 26 DC Level 27 <br /> Normal J Rush'J I-J H _J III J Project Specific (specify) in <br /> 1 Relinquished by 2a - rr Date i- - i ( 1 Received by 2§' I Date i t ' r <br /> (Signature/Affiliation] +i .� -} 3L Time i(r� i CJ (Signature/Affilsatiojn-41; Time p <br /> 2 Relinquished by Date 2 Received by Date Ln <br /> (Signature/Affiliation) Time (Signature/Affiliation) Time <br /> 3 Relinquished by Date 3 Received by Date <br /> (Signature/Affiliation) Time (Signature/Affiliation) Time <br /> , <br /> Comments 29 <br /> Mrnai5gl <br />