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INTERNATIONAL ANALYSIS REQUEST AND Reference Document No. <br /> OLOGY <br /> CORPORATION CHAIN OF CUSTODY RECORD* Page 1 of �- <br /> Project Name/No Samples Shipment Date 7 Bill to 5 17 - <br /> Sample Team Members 2 Lab Destination ' 1 r — o <br /> Profit Center No 3 ---- __� Lab Contact 9_—�� <br /> Project Manager!�� (J1P�C'Z`�vt l) Project Contact/Phone 12�. 3t%� Report to �� `�-'' . 4S �' '� m <br /> Purchase Omer No 6_ C' Z' Camer/Waybfll No 13 m <br /> Required Report DateWe 1111 MR @111k 1 i _ , <br /> Sample 14 Sample 15 Date/Time ifi Container Sampler Pre 19 Requested Testing 20 Condmon an 21 Disposal 22 <br /> Number Gescn twn Collected T Volume serwaUwe ram pease t F Amwrd No <br /> -� t �� / L <br /> n <br /> I <br /> MID 11 Mob <br /> 0 <br /> UZI <br /> 17%J 11160 <br /> rn <br /> m <br /> cif <br /> Cr <br /> m <br /> n <br /> IEPSpecial Instructions 23 <br /> Possible VJ20rd identification za Sample Disposal 25 M <br /> Non-haza Flammable FJ- Sian Irritant Polson B [--IUnknownReturn to Client LJ Disposal by L Archive [mos l <br /> Turnaro nd Time quired 2 �1(� C Leve! 27 m <br /> Normal Ru$ /1 I li l_j III IJ Prn ect specific (s e ____ - — I <br /> - 2a Date W (�t� <br /> 1 Relinquished b Date 1 Received by <br /> nawre Affil,auon .1�� Time [Signature/Affihatron) Time a <br /> {Srg / I <br /> 2 Relinquished by Date __ 2 Received by Date W <br /> (Sgriewre/Aff"Uon) Time I&gnature/Alfdietrunl Time <br /> 3 Relinquished by Date 3 Received by Date <br /> [Sgiawre/Affiiiauunl Time (5gnature/Affihauun] Time <br /> Comments 29 <br /> MCA 3!15191 <br />