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Chain-of Custody Number ` <br /> SECQR Chain-ofTCustody Record 6% - 03- 3(M <br /> f=teid Office �f��fa"`e"� SGc°t: <br /> Additional documents are attached, and are a part of this Record <br /> Address 1-739 3y Job Name 7j-e,,Xuc a <br /> 5 Acr,Apv,�0 c Location y N o west C huff f ef% ►NA y - <br /> l'roiecl # A9001-00 "ol Task # C h,+Oq Analysis Request <br /> Nrnlecl Manager JD�A BO'iJP-r T <br /> N <br /> I aboratory ( 1 0 Z '1� C <br /> itmiaround Time - Pr a m y y �� ,CL <br /> l-7 <br /> SJ C <br /> -FT WV <br /> _ / os <br /> Sampler's Name �'s pQopIRbm <br /> Samplers Signature cm cM o _3 L oQE <br /> � 1 COt�ments/ <br /> Sample ID Date Time Matrix Xm m 11 �� I <br /> Instructions <br /> :=1 r _ 3 y q'15 Mr I I <br /> FF 3N 9'ov 6r <br /> I-,lwr wl InSiriu lions/Coinmenls Relinquished by Sample Receipt <br /> Sign Sign Total no of containers 2- <br /> �'� 5 Print C�r9 C II'Fr Print Chain of custody seals <br /> Company . Eto4, Company Recd in good condition/cold <br /> Time Date Time `� Date Conforms to record <br /> Relmqul ed e m d by <br /> (7AO yS6 -v t t c� Sign Sign Client �rro <br /> Print Prin <br /> Company Company Client Contact 3" &1�� <br /> Time O Date - Time - - - D t - Client Phone 6454-4"3 <br /> gil17 I IIFC 7T,7_51 I -- <br /> Date �._....L...116 f age_-_( of <br />