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!o W err W WW OR No "* NE1►��1 <br /> nt rr <br /> Cham o <br /> Custody Record <br /> OUA-4124 0797 <br /> Client Project Manager Date jj Chain of Custody Numbe <br /> S � 4rl_ �- t Z 'r-r3 I i $,2 2 <br /> AddrTeleph tuber(Area Code)lFax Number Lab Number <br /> 916 <br /> 3 g Page _ of <br /> S a Z+p Code n Site Contact Lab Contact Analysis(Attach list if <br /> f �.�,� '7 r 111 mores ace is needed <br /> Pro ect Name w 'V �^O Carner/Waybill Number <br /> f7" Special Instructions/ <br /> ContractlPurchase Order/Quote No Containers& Conditions of Receipt <br /> 1 `O 1-7 Matrix Preservatives <br /> Sample I D No and Description pate Time <br /> (Containers for each sample may be combined on one line) <br /> Mw- � r3S <br /> 6 l n <br /> Possible Hazard Identification Sample Disposal <br /> (A les may be assessed if samples are retained <br /> ❑ Non Hazard ❑ Flammable ❑ Skin Irritant ❑ Poison B ❑ Unknown ❑ Return To Client ❑ Disposal By tab ❑Archive For Months longer than 3 months) <br /> Turn Around Time Required QC Requirements(Specify) <br /> ❑24 Hours ❑ 48 Hours ❑ 7 Days ❑ 14 Days ❑ 21 Days ❑ other <br /> 1 Relinq By Date p Time �/ I Received By Date T+m0 <br /> 7XV112. ZO Vk <br /> 2 W& shed By Date Time 2 Received By Date time <br /> 3 Relinquished By Date Time 3 Received BY Date Time <br /> Comments <br /> DISTRIOUT7ON WHITE Stays with the Sample, CANARY Returned to Client with Report PINK Field Copy <br />