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Chain ofSTL <br /> CA Custody Record Severn Trent Laboratories, inc. <br /> STL-4124 (0901) <br /> Client (j Project Manager Date Chain of Custody Number <br /> aY1 J o� - y Z - D100263 <br /> Address Telephone Number(Area Code)/Fax Number Lab Number <br /> S/(o' '7d'w /S 7 / Iq f(o , -2 S(G . v3(op I Page l of <br /> City State Ip Code Site Contact Lab Contact Analysis(Attach list it <br /> mores ace is needed <br /> Project Name and Location(Stare) CarrierANaybill Number V M h \k <br /> 7p-,4ey r�r AZE Frac r—AO4 C)/ C'ft— �' t ? �`1 �j- ` <br /> ConbacVPutchass Order/ouote No. G �1 W M S X Special Instructions/ <br /> aD Matrix Containers& ,.,) y 0 m o S. Conditions of Receipt <br /> 3' o qa z s - n z /coo Preservatives b <br /> Sample I.D.No.and Description <br /> ( p y ) Date Time 3 o `o , nj <br /> Containers for each sample maybe combinedon one line ' _ N i J Vt �J <br /> X )' JeX X X )C K GJj..vt�a..E�. No T- <br /> p4-2x-a3 rZga X >' 2 / c/ / ! X C X x )C )C s! se 3C F <br /> 1 c�-o c=1 L_-ti-Zz-D. <br /> v ( A <br /> 0 <br /> u1 y✓©:'v <br /> w RE EIV D I U T T <br /> N <br /> 8 <br /> P 22 01,1113 <br /> II <br /> Possible Hazard Identification Sample Disposal -- <br /> (A fee may be assessed it samples are retained <br /> NomEl ❑Skin irritantC1Polson B Unknown ❑ Retu1 ient ❑ Disposal By Lab ❑Archive For�_ trtomhs longer than I month) <br /> Turn Around und Time Required OC Requirements(Specify) <br /> ❑24 Hours ❑ 48 ours ❑ 7 Days ❑ 14 Days ❑21 Days Ott fir V-`) `'k <br /> Z! <br /> uishe Date T'me- ' 1.ReceiveaD <br /> �............. J Date Time <br /> I�('-22'23 <br /> 2. dBy Dafe Time 2.Received y Dale Time <br /> 3.Relinquished By Dale Time 3.Received By Date Time <br /> Comments <br /> 1n <br /> 0 <br /> rn DISTRIBUTION: WHITE-Roturnad to Client with Report: CANARY.Stays with the Sample: PINK-Field Copy <br />