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Chain o ►iivanterr <br /> Custody Record <br /> OUA-4124 0797 <br /> Client , Protect Manager DateCharas of Custody Numb <br /> M� t r c � Z ?v ��S 26822 <br /> Addie s(�i nn Telepho rinber(Area Code)IFax Number-� Lab NumberRL 4k I I <br /> Page.- 1 of —L-- <br /> CI Sta ip Code Site Contact Lab Contact Analysis(Attach list if <br /> mores ace is needed <br /> x <br /> NaM <br /> Camer/Waybili Number <br /> C -r' <br /> ContracUPurcSpecial Instructions/ <br /> Matrix <br /> Order/Quote No <br /> Matrix Containers& n Conditions of Receipt <br /> 1 — Preservatives r v <br /> Sample I D No and Description o z x71 Z <br /> (Containers for eachsample ma be combined on one tine) Date Time x <br /> W ``o c N <br /> y a x x xz <br /> 1 <br /> -�- ' <br /> Mw- L 13� <br /> l) <br /> 01� <br /> r 0 <br /> c,J- 77 (Z12 alq 'Zo <br /> Possible Hazard Identification sample Disposal <br /> (A lee may be assessed if samples are retained <br /> ❑ Non Hazard ❑ Fiammabie ❑ Skin Irritant ❑ Poison B ❑ Unknown 10 Return To Client ❑ Disposal By Lab ❑Archrve For Months longer than 3 months) <br /> Turn Around Time Required QC Requirements(Specify) <br /> 1124 Hours ❑ 48 Hours ❑ 7 Days ❑ 14 Days ❑ 21 Days ❑ Other Y <br /> t Relinq d 8y Q r Date rr T i Received By DateTrme <br /> �bL/ 111, <br /> , 11' I/t r i <br /> 2 R&4LtshLd By Date Time 2 Received By Date Time <br /> 3 Relinquished By Date Time 3 Received By Dare rime <br /> Comments <br /> DISTRIBUTION WHITE Stays with the Sample CANARY-Returned to Client with Report PINK Field Copy <br />