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Sample Chain-of-Custody/Analysis Request <br />61L ;/5 --I �, ,, �7 <br />Kennedy/Jenks Consultants <br />Possible Ha",d.' <br />site <br />Sampler Name <br />Teleph.�e Fax <br />a <br />•Carrier/Way <br />DestinationClient <br />Address <br />Telephone <br />Bill No. <br />5ik9i 5w{� <br />MEN <br />RAO IMMINMIN© <br />NoII <br />.Mil. <br />__ ■■ ■■■ <br />■.�.. <br />■■� <br />__ ■■ ■■■ <br />MIENS <br />MIM <br />(1) Wme only one sample number in each space. (4) Preservalion of sample. <br />(2) Specify type of swple(s): Water (W), Solid (S), or Indicate type. a Wme each anatysls requested across top. Place an'V In appmpdale oolumn to <br />(3) Mark each sampie whL-h should be mmpo bed in Laboratory as tallows: Placa an °A' In box to each sample that shouldbe cwV)aWted into one sample; use sequemial lever for addlional groups. indicate type of an*sis needed for each sample. <br />Kennedy/Jenks Consultants, Inc. © 20011 <br />