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>>>select a Laboratory<<< �� !� Chain of Custody Record rt ef ,may <br /> #NIA 11 �J � i��1 0 <br /> #NIA 1 TKE LFF➢Est IN CNV[RCNMOrAL TI1S;TlNG N <br /> #N/A (ILL ffff LL I� <br /> #NIA Regulatory Program: ❑DW ❑NPDFS ❑RCRA ❑other: TestAmerica Laboratorles,Inc. <br /> 0 <br /> Client Contact Project Manager: - Site Contact. L)-, Data: COC No: <br /> Your Company Name here /(/ TeI/F— Z Lab Contact Carrier: of COCs <br /> Address fimalyslsrTurnaround Time Sampler: <br /> City/StateMp S pZ ❑ CAIFNDAR DAYS Ll WORKING DAYS Q For Lab Use Only- <br /> (—)x a x ooc Phoney 10 TAT if different from Below z Walk-in Client: <br /> ()oa):=-:a= FAX Lj 2weeks Z} Lab Sampling: <br /> Project Name: 1 week `> o <br /> Site: j �/G ❑ 2 days m q Job/SOG No.: <br /> PO# 4` <br /> ❑ 1 day E y N d <br /> amp c (n N a. <br /> Type @ !S0 <br /> Sample Sample two P Sof ,, -c y x t <br /> Sample Identification Date Time c� b) Matrix coat a F O Sample Specific Notes: <br /> L CR <br /> CV <br /> O <br /> Ln <br /> O <br /> (D <br /> D_ <br /> 720-74752 Chain of Custody <br /> Preservation Used: 1=Ice, 2=HCI; 3=H2SO4; 4=HNO3; 5=NaOH;6=Other XI <br /> Possible Hazard identification: Sample Disposal(A fee may be assessed If samples are retalned longer than 1 month) <br /> Are any sampies from a listed EPA Hazardous Waste? Please List any EPA Waste Codes for the sample in the <br /> Comments Section if the lab Is to dispose of the sample. <br /> L j Non-Hazard J Flammable Sian Imtant ❑Poison 8 ❑Unimown Lf Rehm m Client LI Disposal by Lab ❑Archve for Months <br /> Special Instructions/QC Requirements&Comments: <br /> Custody Seats ly4act v t] No Custody Sea]No.: Cooler Temp. C):Obs'd: CoWd: Therm ID No.: <br /> Relinquished by. Company: PD-t-mm-- <br /> Received by: Company. Date/Time: <br /> �'vV//I/�-J) C�'t 7 4 To+wc? 111-7(1(r- <br /> Re <br /> z-r ICF <br /> Relin iqu stiedb Cca^ny: Received by. Company: DatetTme: <br /> Relinquished by: Company. R2Cqived in Laboratory by: Co pang. Da C m U <br /> Form No.CA-C-WI-002,Rev.4,3,dated 12105!2013 <br /> • � � mac._ i <br />