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v <br />INTERNATIONAL R/A Control No. < .r <br />TECHNOLOGY CHAIN -OF -CUSTODY RECORD <br />CORPORATION <br />C/C Control No. 171058 <br />PROJECT NAME/NUMBER }macx, ! e PIC, /< LAB DESTINATION ..S4t,2:k - <br />SAMPLE TEAM MEMBERS - I, fkfl)e9.rr._ CARRIER/WAYBILL NO. <br />Sample <br />Number <br />Sample <br />Location and Description <br />Date and Time <br />Collected <br />Sample <br />Type <br />Container <br />Type <br />Condition on Receipt <br />(Name and Date) <br />Disposal <br />Record No. <br />tt 5 <br />Special Instructions: <br />Possible Sample Hazards: <br />SIGNATURES: (Name, Company, Date and Time) <br />2 <br />Relinquished By: OL ' , 1 elinquished By: <br />Received 6y----- Received by: — <br />Relinquished By: 4. Relinquished By: <br />Received By: <br />WHITE - To accompany samples <br />YELLOW - Field copy <br />Received By: <br />