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04TERNA'noNAL ANALYSIS REQUEST AND Reference Document No <br /> ® TECHOLCGY <br /> r <br /> CORPQATIORAMNCHAIN OF CUSTODY RECORD* Page 1 of <br /> CORP <br /> JAr <br /> Project Name/No _ Samples Shipment Date 7 Bill to __-T 8-f` <br /> Sample Team Members 2 _ Lab Destination a ' /? 3 y o <br /> Profit Center No 3 — Lab Contact <br /> Project Manager Project Contact/Phone 12 ���� 3360 C� <br /> Report to 1° <br /> Purchase Order Na s n �� _ Carrler/1Naybdl No 13 m <br /> Required Report Date 1 _— _ ,-__ • • <br /> Sample 14 Sample 15 Date/Time 16 Container 17SOmplele Pre. 18 Requested Testing 20 Condition on 21 Disposal 22 <br /> in <br /> Number Descnpbon/TVPe Collected Type Volume servatwe !ram Remipt Record No. <br /> °iIo <br /> CL <br /> IWLJ LOT <br /> n Its <br /> Mr. n En <br /> ro <br /> MW VMV� low ro <br /> c <br /> m <br /> rs <br /> Special Instructions 23 E' <br /> Possible H rd Identification. 24 Sample Disposal 25 <br /> Non-hazard Flammable 17,1 Skin Imtant 13 Poison B ra Unknown Lk Return to Client Disposal by Lab�K Archive_ - lmcs ] m <br /> n <br /> Turnarp,pnd Time Required 26 Level 27 -f <br /> Normal RushF 1j 1 II IJ III IJ Project Specific (specify], <br /> 1 Relinquished by 2a -r ate $9 1 Received by 26 Date <br /> IS�gnswrefAffivauonl - Ime (s,gnswre/airi�etioll) Time <br /> 2 Relinquished by Date 2 Received by <br /> Date <br /> l$tgfiBTi" AffithBuml Time Time <br /> 3 Relinquished by Date - 3 Received b Date <br /> (.51gnawm/Affilmmn) Time ( G1re�Aifihationl ? Time <br /> Comments 29 <br /> I <br /> MCA 311591 <br /> eei� �� IIS � �� � � � � w� � � � �� � � I♦ <br />