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INTERNATIONAL ANALYSIS REQUEST AND Reference Document No <br /> TECHNOLOGYFE- CHAIN OF CUSTODY RE ORO* Pagel <br /> 9 l of-- -�- � <br /> Project Name/No }- r Samples Shipment Date ? I � Z�1 Bill to s _ ----- <br /> Sample Team Members 2__— �� _ Lab Destination <br /> Profit Center No s_ CL�- Lab Contact _ _ ___ _____ - n <br /> Project Manager4 _ �,�-C. �'L �1�__-- Project Contact/Phone 12 �' �'L- Report to 10--- <br /> Purchase Order Nos tS�'s � �� Carrier/Waybill No 13 - <br /> Required Report Date <br /> rr-antain 16 i 1s 2a 21 22 <br /> Sample 14 Sample 1 Dale/Tuno Sample Pre- Raqueatad Testing Condit►an an DsupasalNumber Des tann j allottedVolume sarvatwe program Rm mit Record No. <br /> if tv nom <br /> ill) I� Sam # a <br /> -- n <br /> mal muff JR1111 E (D <br /> n <br /> Cr <br /> M <br /> n <br /> _ x <br /> 0 <br /> Special Instructions 23 <br /> Possible Ftazard Identification 24 Sample Disposal 25 - <br /> Ae <br /> Non-hazard7A— Flammable FJ Skin irritant IA Polson B 1_1 unknown 1-1 Return to Client 1J Disposal byI_ab Archive ___ _ (mos ) � <br /> L <br /> Turnaround Timequired 26 e-), r GIC Level 27 <br /> Normal Ji Rush c7"- ( ,, I a, it 1y III IJ project Specific lspucm, <br /> 1 Relinquished by 2d � E Date 1 ( Z 1 Received by 2e Date I <br /> tStgndture/�Alfihaunni L 1— ��r Time r j C ISwgriawre/AffhaGun) Ime L j <br /> a <br /> 2 Relinquished by Date _ 2 Received by Date <br /> (S+gi wUff-L/Afhhduonl Time fSignawm/Affihatwnl Time <br /> 3 Relinquished by Date _ -�--� 3 Received by Date _ <br /> tsohdWre/Afuhduunf Time ISignausm/Afrihauun) Time <br /> Comments 29 <br />