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Sample Chain-of-Custody/Analysis Request <br />IU�IINf'�W�VInIV <br />/3 i k <br />Kennedy/Jenks Consultants <br />Tossible <br />Destination <br />ClientS ff.■ I� <br />\ / / r <br />Com <br />Project No. 111�0(0. 2.06 <br />Address iAh <br />Sampler Name M .A clitV <br />Telephone 41E 7-13 Zrd 9 FaxA <br />Carrier/Way Bill No. Vj 1",• <br />WEAN <br />©. E �law=MIUMZii <br />■■■ <br />rAAVO._RI■■©■■■■MIME <br />© ..M.IMERIMIN■. <br />©.. .�...®.,.,..©.1■■■■■ <br />■■■■■ <br />(1) Write only one sample number in each apace. (4) Preservation of sample. <br />(2) Specify type of sample(s): Water (W), Solid (S), or indicate type. M Write each analysis requested across top. Place an "X" in appropriate colwm to <br />(3) Mark each sample which should be oomposded in laboratory as follows: Place an W in hoz Mr each sample that should be composited into one sample; use sequential letler for additional groups. indicate type of analysis needed for each sample. <br />Onnedy/Anks Consultants, Inc. Oo 2001 ,f C <br />