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Sample Chain-of-Custody/Analysis Request <br />i��IIIII��fli�II�4V� <br />Pae-- 1 /3 Hwk71 <br />Kennedy/Jenks Consultants <br />it <br />'ossible Hazards tv� <br />Lab Destination <br />Client Paport to <br />/ <br />ProjactN.. "4 Address .3200 <br />Sampler Name M 4 64 Od <br />Telephone <br />Telephone r- 7 i ' <br />Fax <br />Carrier/Way Bill No. <br />r.;;� A j+.rr a'�. �Y u x�%n����k�+fi�+' t_. x� �1, gar-"�tri� ���+,s,`�4 �,�<+>�d't■ <br />t 4R v.. - ,_ �7l•,fpi`�_, <br />— <br />_...�,�+t,�,y�naa'1d._i��r�U6,KY�1pV <br />a E1 '' 1J ',,,LaxASWM <br />11NUUMNItlM13�■■■■■FROMM■ <br />©. 0101MMffJi]■■130■■■■■■ <br />(1) Write only one sample number in each space. (4) Press"affen of sample. <br />(2) Specify type of sample(s): Water (W), Solid (S), or indicate type. (5) Write each analysis requested across lop. Place an'X' in appropriate column to <br />(3) Mark each sample which should be composited in Laboratory as follows: Place an'Ain box for each sample that should be composted into one sample; use sequential letter for add* nal groups. indicate type of analysis needed for each sample. <br />4 .'s; { iits._i: tM 31, WW"ji :�I <br />i1:917AM <br />i ..� -����7�YIG���iL"'� %iii . �'•'� � <br />r. <br />Kennedy/Jenks Consultants, Inc. 0 2001 71 <br />