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G) <br /> 0 <br /> Chain of <br /> Custody Record STL <br /> $TL-4124 '(Mn Severn Trent Laboratories, Inc. <br /> Gent <br /> `Pro%BCf Manager <br /> Chain ofCuslodyNumber <br /> Address `J A4 6:s ;'! � �- /0 0 129426 <br /> Telephone Number(Area Code)/Pax Number <br /> �r70 s�CryS(r,s>;� $G.i/ Lab Number <br /> wy, statezip cads 9 tc4 - -7 b'Ca O3 Zb 1-716 <br /> Site Contact Lab lContact Page of^ Analysis(Attach list if <br /> Project Name and Location(State) more S 7ace is ne led <br /> CarrierNYaybRl Number �, <br /> �'�•t-CY �''r lZtr F[aZ cs' T�-Gy� G�rk- � f <br /> ConlracVPurchase plderlOuole No. -+y <br /> o b 3 — 4�i U� Matrix Containers& �`+, 0 9 Special Irrstr Receipt d ' Preservatives -� Conditions of Receipt <br /> Sample 1.0.No.and Description Wr <br /> (Containers for each sample may be combined on one tine) 'pate Time $ o o �o � � \r <br /> XA <br /> ta .o�.o3 <br /> /Zap KaX <br /> CD //o X <br /> �c x X <br /> r Soo aC <br /> w •rw-�r� f3 c.�..,r I4 � � K X K X X fC - <br /> Passlbta Hazard tdent;l;catian <br /> Sample Disposal <br /> ❑Non-Hazard ❑flammable ❑ Skin trrilarN ❑poison g UV&v vn (A fee may be assessed if samples are retained <br /> Turn Around 77me Required ❑Return To Client disposal By Lab ❑Archive For Months longer than 1 month) <br /> ❑12. ' <br /> rs ❑ 49 urs ❑ 7 Days QC Requirements(Specify) <br /> h Y ❑ fA Days ❑21 Days Uleho q <br /> Date Time 1.Rec elf 8y <br /> (� �► Y3a fDraatee Ta[m�e <br /> slay 1�`r" 1 : � <br /> Date Time 2.Rec 'ed BY <br /> ' rma <br /> J.Rallnqurshed gy Date . <br /> Date Time 3.Received$y <br /> Commanls Date Tana . <br /> 41D1STR1HUT10N: WHITE-Returned to Cf' nl with Report; CANARY <br /> 0 -Stays with the Sample: PINK-Field Copy <br /> cp <br /> M <br />