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»>Select a Laboratory<<< Chain of Custody Record <br /> #NIA72 � ! es}AmQda <br /> 0 <br /> #NIA Z I 7xe LEs.DEa N cvvkaoNMEWAL 11STING N <br /> #NIA Regulatory Program: ❑Dw ❑NPDB ❑RcRA ❑other: TestAmerica Laboratorles,Inc. <br /> 0 <br /> Client Contact Project Manager: &- Site Contact. Data: COC No: <br /> Your Company Name here /j/ Tel/Fax Z r{S— Lab Contact: Carrier: of COCs <br /> Address AnarySis Turnaround Time f� Sampler. <br /> City/State/Zip 9'5-ao6 Q CAUNDAR DAYS wOPJCMG DAYS For Lab Use Only: <br /> {xcc)�ooax�ooc Phoneo TAT ifcfferwtfromaelow Z Walk-in Client <br /> 0000— FAX U 2 weeks Z y Lal?Sampling: <br /> Project Name: U 1 week i. a <br /> Site: S ��G / ❑ 2 days a co Q .` ` Job/SDG No.: <br /> PO# ❑ Iday E= m <br /> Sample- <br /> a E <br /> Sample Sample i� eP. sof y <br /> Sample Identification Date Time wG�o) Matrix cart ,_ a F O Sample Specific Notes: <br /> 5' �/ /r'�s��oY�2� z •� �1.3�/ G k <br /> (V <br /> .a- <br /> O <br /> CD <br /> CM <br /> 720-74752 Chain of Custody <br /> Preservation Used: 1=Ice, 2=HCI; 3=H2SO4; 4=1-[NO3; 5=NaOH;6=Other <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 /> LJ <br /> ample_L j Non-Ha.rd J Femnwbie Skin LTitant C Polson 8 ❑Unimown U Rehm m Client U Disposal by Lab ❑Ardiive for Months <br /> Special InstructionslQC Requirements&Comments: <br /> i <br /> c <br /> Custody Seals I pact t] No Custody Seal No.: Cooler Temp. C):Obs'd: Corr d: Therm ID No.: <br /> Relinquished by. Com an DateTme: Received by. Company. DaterFime: <br /> �/ /y <br /> Rel'n fishedb K C Upa^y: <br /> at" <br /> e Received by Company: Date�me: <br /> Relinquished by. Company. DatelTime: Re ved in Laboratory by: Co pan . Da mIh <br /> U <br /> Form No.CA -WI-002,Rev.4.3,dated 12/05/2013 <br /> • t `'c_ <br />