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Chain stodv Number <br /> 'i <br /> SECCi R Chain-of Custody Record <br /> I <br /> Field Office _. <br /> SF..CD 1 11 UAdditional documents are attached, and are a part of this Record <br /> o WO(OW0�5 CO 514 3l10 Job Name %ac O <br /> Address fl WAS C c 0-14r l.0 A <br /> A Location <br /> q�ISI � �C <br /> Analysis Request <br /> Project # 1 V°fib) -4 b 02 Task # od <br /> Project Manager abhA o� <br /> 15 I N <br /> ° <br /> Laboratory c `�N � 0 a <br /> Turnaround Time a a v � ca � y <br /> C� p m y U <br /> Cert, i UJ' r >v OD M0 !�v Nv c�C dam-' m 67 <br /> Samplers Name �- a v C— ?r- -0 CO E <br /> Sampler's Signature a �,N = _ E 0 �° o m N N pro a Comments/ z <br /> U do a o a °a K 0S dN °o oar � �' U <br /> Sample ID Date Time Matrix s w i*CO ►- ¢( >( s m 0.'° r r` 0. Instructions <br /> -r z'3o Ar X III 1 <br /> 11-- 12- <br /> Special Instructions/Comments Rel inqui"hed b ,_St-Co Recelvej by G Sample Receipt <br /> Sign ('1. A-- Sign Total no of containers <br /> Prirrt Prin� � — Chain of custody seals <br /> Co" pan" SE ftp Company Af/7� Rec'd in good condition/cold <br /> Time 3' S Date of- Time /3..� Date 1 Conforms to record <br /> Relinquiii hObV4Q Receivedby <br /> Sign SignS-Ct.aQ.c.4g]S ClientPririt IIPrint S .2r7cJS. 1 T�-! - Client Contact TOID rQwJCompanyCompany622± <br /> Time J ��� Date y Time _ �,�DDate—HIEN ¢ <br /> a-- Client Phoneq/ z1 1- 3-- <br /> I 6 <br /> SECM CUSTREC Rev 195 <br /> Date / Page_ , of <br /> • �► • <br />