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0 <br /> Chain-of Custody Number 23�S <br /> SECQR Chain-of Custody Record 5-gs-0 Zf <br /> Field Office 's 4 ^D D Additional documents are attached, and are a part of this Record <br /> Address 5 Job Name - <br /> Location . <br /> Project# — ®I Task Analysis Request <br /> Project Manager _ <br /> Laboratory GALL e4tem _ Q �2 U 2 <br /> Turnaround Time 22 <br /> N <br /> LD G1 [C U (3 U 3 ti {) <br /> Sampler's Name A A4v)6-W . 1 F-0 o ao u o p o ca o m o m o m $r <br /> Sampler's Signature 00 v m 0o °'N o N -°o y 2 <br /> p r x r x o a °'� Lo y W a o a Comments/ <br /> I <br /> Sam le ID Date Time Matrix = �ago i1—coo ¢w 0 S n cn o a n r- a H Instructions <br /> W- S 1 .tD 3 <br /> w 3- 33y <br /> W- k 18• <br /> Special Instructions/Comments Relinqui Relinquished by Sample Receipt <br /> Sign Sign Total no of containers <br /> Print n�, �,j�ia _ Print Chain of custody seals <br /> Company Company Recd in good condition/cold / <br /> Time ==LQ4=,0==ft Date Time Date Conforms to record <br /> Relinquished by Relinquished by <br /> Sign Sign Client SCcoti _ <br /> Print Print Client Contact J 6. <br /> Company�E�{[e le em Company <br /> Time Date 5'/?_ Time Date Ch nt P ne4161 Me <br /> -D <br /> SECOA CUSTREC Rev 9144 <br /> Date 5 Z I °� Page of <br />