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V2 ARCADIS <br /> Laboratory Task Order N -01-CUSTODY RECORD . Page of <br /> Project Number/Name ANALYSIS fMETHOD !SIZE <br /> Project Location <br /> Laboratory <br /> Project Manager/77 , <br /> S mpler(d/A iliatio <br /> Datefri me <br /> Sample IFIL tion Matrix Sampled Lab ID •Remarks Total <br /> -� <br /> 3-1 145 <br /> ro <br /> 1 ' <br /> w 9A_4A_1 S1190 X <br /> o . <br /> w �- - v0750 <br /> ' <br /> 'gn ' <br /> - j <br /> 14 A -6 6qlD <br /> Sample Matrix: L = Liquid, S = Solid, A = Air Total No, of Ruttiest <br /> Containers <br /> Relinquished by: Organization:-! Date t I Time 15 Seal Intact? <br /> r Received by: Organization: Date +_Ld � Time—ZO Yes No BRA <br /> Relinquished by: Organization: Date IL Time Seal Intact? <br /> Received by: Organization: Date i Time Yes No N/A <br /> Special Instructions/Remarks: <br /> Delivery Method: CI In Person O Common Carrier Cl Lala Courier ❑Other <br /> SPECIFY SPECIFY <br /> AG OS-12MI <br />