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M M = = M M IF = = = = = -' ino !orm w <br /> n+a<TERNATIONAL ANALYSIS REQUEST AND Reference Document No <br /> TECHNOLOGY <br /> CORPORATION �� CHAIN OF CUSTODY RECORD* 9 <br /> b�rM Pa e '1 of <br /> ., ,, <br /> Project Name/No ��}' ��G �f 'amples Shipment Date ! Bill to 5 !-T 74— <br /> Sample-Team Members �bn1 e r .�,�e�c� �-�u� <br /> ' ___ Lab Destination �Y.�+���rtr s� <br /> Profit Center No �7?Z7/C3 Lab Contact 9 -J�yv-� T �r _ <br /> r. ` - — - -- — - - - h <br /> Project Managerq S•G � Protect Contact/Phone 1 �.�,ibnJ g7z sz 10 <br /> �___�.___, � Report to t� ��U'�= wPurchase Order No 6 Carrier/Waybill No 13 A-)11-? <br /> Required Report Date <br /> 0 <br /> Sample 14 Sample 15 Date/Time 16 Containerl Sample Pre- 1 9 Requested Testing 20 Condition on ?1 Disposal 22 N <br /> Number Description/Type Collected Type Volume servativa Program Receipt Record No <br /> b <br /> t <br /> APIA <br /> ,i <br /> S� S ``L <br /> rr Y n <br /> 0 <br /> I <br /> • SCA � '�S <br /> Cr <br /> n <br /> Special Instructions- 23 0 <br /> Possible Haz Identification 24Sample Disposal 25 <br /> Nwl-hezardOIJ Flammable I J Skin Irritant IJ Poison B IJ unknown I J Return to Client IJ Drs ' <br /> --1 Disposal b Y LabArchive (mos ) s, <br /> Turnaround Time Required 2B DC Level 21 �4 <br /> Normal I-) RushIJ V1 1 IJ II IJ 111 1-1 Pro act Specific (s e I ; <br /> 1. Relinquished-b� Date 1 neceivecfTy-2P Date <br /> :&parr/arnretwnt Time ��� 7 1519FIBLUM/Atld,ution G� Tim // <br /> 2. Relinquished by Date 2 Received b \ pate G .y <br /> f ""' Time 15icgnature/Aff liatiun) Time <br /> 1317.-,Relinquished by Date 3 Received by Date <br /> SWAN0=1Time (S anature/Afft:iaaonj <br /> Time <br /> mments•as <br />