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INTERNATIONAL ANALYSIS REQUEST AND Reference Document No <br /> TECHNOLOGY CHAIN OF CUSTODY RECORD* Pae 1 of <br /> co�ou�l7oN 9 <br /> Project Name/Nn cr Samples Shipment Date �_J� '��—_ Bill to 5 <br /> Sample Team Members -�-- Lab Destination <br /> Profit Center Nos , Lab Contacts a <br /> 12 -- _Project Mana er4 b.L-_ Project Contact/Phone _9 _ <br /> _ - r 1- - - _0 <br /> 10 <br /> s 1s Report to <br /> Purchase Order No Carder/Waybl No -- <br /> - o <br /> t, <br /> C, <br /> Required Report Date �_- _ --_ ----- --- ----- <br /> • • + <br /> _ - ro <br /> Sample 14- Sample 15 Dote/rime16 Container) Sample) Pro- » Requested Testing 20 21` Disposal 22 <br /> Number Description/TypeCoilsVolume serate prC t Record No <br /> CTS �� e � L T <br /> airn <br /> f�-� � apt i I�� i <br /> � <br /> 1 V <br /> I�UR LS <br /> l rr IMI! _n <br /> a <br /> UZ311t 10 LY <br /> [) <br /> C-� <br /> 1J r 11 <br /> Y 1 <br /> %AV%w 111011 Inman <br /> \VV <br /> _ @ <br /> Y ) L y <br /> U� <br /> Special Instructions 23 <br /> Possible Fjpzard Identification 24 Sample Disposal 25 a <br /> Non-hazard Flammable n..J Skln Irritant Polson a IJ Unknown FJ Return to Client fJ Disposal by Lab Archive_ _— (mos ) <br /> n <br /> Turnara nd Time Required 26 _ <br /> Level 27 <br /> Normal — Rushrj ' I II lJ III C,J Project Specific IspegbA _ -- -- -- F - —-- — <br /> 1 Relinquished by j Date —� _f ___ 1 Received by 2a to <br /> iSrgnature/AFfrlrsuonl ]I ! Time `� (Srgn©tore/Affihatxxr) Time i / <br /> CPI <br /> 2 Relinquished by date _ 2 Received by Date <br /> iSrgi rdtur a/Affilmuanl Time J&g,rsture/Alfihauunl Time <br /> 3 Relinquished by Date — -- 3 Received by Date --- <br /> [Signature/Allrhduunl Time (Sgnawre/Af6bauunl Time <br /> Comments 29 <br /> Ask ANIL Ji <br /> ... _ .r Ilr ® ■■>. r r rwern r r� r rills r r r�r <br />