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INTERNATIONAL a ®& �® ) R/A Control No. 1113112 <br />TECHNOLOGY CHAIN -OF -CUSTODY RECORD <br />CORPORATION <br />C/C Control No. 171184 <br />PROJECT NAME/NUMBER LAB DESTINATION SArnJ�e, C-`G�-C,.- <br />SAMPLE TEAM MEMBERS J 0 Knoll— CARRIER/WAYBILL NO. <br />Sample <br />Number <br />Sample <br />Location and Description <br />Date and Time Sample <br />Collected Type <br />Container Condition on Receipt <br />Type (Name and Date) <br />Disposal <br />Record No. <br />® <br />iia- <br />,I <br />/OluyS®� <br />, <br />c/ 4P./k Q- <br />6 <br />SS - <br />0 r <br />y <br />Special Instructions: <br />Possible Sample Hazards: <br />SIGNATURES: (Name, Company, Date and Time) <br />1. Relinquished By: ' ry ® q00 <br />SS fib 0(®- o1a" 4® 40 cc <br />Received By: -TV ALt" <br />2. Relinquis <br />Received <br />WHITE - To accompany samples <br />YELLOW - Field copy <br />3. Relinqu <br />Receive <br />4. Relinquished By: <br />Received By: <br />