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nn it <br /> Cham-of Custody Number <br /> SECOR Chain-of Cu s1tody Record - <br /> ll Additional documents are attached, and are a part of this Record ! <br /> Field Office _ :_;&_r4"kw 132 --- <br /> Address )-7 _ Jolb Nam <br /> —3 e <br /> 0�u <br /> Lo <br /> cation <br /> Analysis Request I <br /> Protect# 7oc�-oog-Q Task # T� <br /> Project Manager. -50hrl I I <br /> Laboratory =o � 1 f <br /> Turnaround Time a o z N U) � m� <br /> LU a- <br /> Sampler's Name 11 i.- E0 �_ Q o o m o21 o a o M l CL r �0 <br /> C.— O[� <br /> Sampler's Signature o ��, o "'m >m m a I' <br /> zr xf = oa �'v °� � �m �N o-- -J Comments) <br /> Sample 0 Date Time Matrix �co �� ►°- ¢` o i(0 U)o a o r°1 a` Instructions I� <br /> -f <br /> loll I l 30 j4;rI — <br /> r a ►�;r l� i -- L <br /> 1 <br /> II I i <br /> II I I <br /> --_- <br /> II i I <br /> Special Instructions/Comments Relinquished by S R u Sample Receipt <br /> Sign Sit" Total no of containers <br /> Print Pniit t Chain of custody seals <br /> Company 5 ' I Company &� Rec'd in good conditionlcold <br /> Time �sa� Date J 0 I Time ' Dated Conforms to record 1 <br /> Relinquished by z I Received by S <br /> Sign Y4-/1101Sign Client <br /> Print Print�v�rrz i Print +)4,V R 3 �� A}� <br /> Client Contact <br /> Company C I Company�R� AZZ-4-CMA <br /> Time ' �� Date Q' TI <br /> Date1� Cllent Phone 416 `fs <br /> SECOR CUSTREC Rev 1195 <br /> Date D 1 1 Page of <br /> I l <br />