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q � yChairs-of Custody Number <br /> SWOR Chair)-of Custody Record <br /> r <br /> Ftefd Office &5IICMMkV Additional documents are attached, and are a part of this Record <br /> Address 3 Job Name - <br /> Location <br /> t <br /> Analysis Request <br /> - <br /> Prolect � -Or?? -!?1 Task 0 AA. <br /> Protect Nlana er JO 4t� <br /> Laboratory�»j <br /> 00 W , <br /> _ <br /> Turnaround Time - 4.��MRw,p a in ru - c <br /> v ❑v a m 8 o po c o <br /> Sampler's Name 12 . /iAV _ A A ' ao j N O c o ono w <br /> Sampler's Signature o �� ,� a E$ m� ao� ' u "' <br /> u n(.o d o b`� o N ,s m o o a (D U COntTYt6ntsl Z <br /> Sample lD Date Time Matrix = r w cc � a i� >w z� �'i w a co �n a.� � Instructions <br /> I <br /> Y <br /> Special Instructions/Cornments Relmqu+sP� �O_ Relinquts by Sample Receipt <br /> Sign _ Sign 9�* "�r�- Total no.of containers <br /> Print n nA�/E?t� Print Gain of custody seals <br /> Company '1� Company t.GLf �{ Beed.in good conditloNcold <br /> '1 Time Date 1441 T06 Tmq..- <br /> ._PAteZWL Conforms to record <br /> Relinquished by d by r �/� <br /> Sign Sign Client XU <br /> Print Print -- Client Contact �d <br /> COmDanv Comoanv C-X91 t 1� M-- <br /> Time Date Time Date Client Phone fV s 3 <br /> Al HEC FW 944k r - --- • <br /> Dale I ...� Page f of <br />