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.t 4 kt-b-4 <br /> INTERNATIONAL. ANALYSIS REQUEST AND t. Reference Document No.TECHNOLOGY <br /> CORPORATION 330726 <br /> - ;� • CHAIN OF CUSTODY.RECDRI] Pae 1. of <br /> Project Name/No. �P _ Sys•3•Z Samples Shipment Date-�� �� z- Bill to. .77 < 1 or ti•,, _ <br /> Sample Team Members? P M4nce r�f�if dun ' a' qr ------ - <br /> 0i <br /> L8b Destination. C4 TV , j <br /> Profit Center No. 3 3��f_�^ " eCotact <br /> �- �' Lb 6 9 12 ' .372-'9 <br /> I 9 5 M f r�S Project Contact/Phone: c�K 1 o <br /> 372-- <br /> Project 1Viana er4_ _Y�y ,. Report to: <br /> 009 13 IT Coy oft��� <br /> Purchase Order No. Carrier/Waybill No:_.� _-_._ � - tn <br /> - <br /> 11 --- - — 8'S �r�tra --- - - - ' <br /> Required Report Date_ -- �2/ Z,- - ---- k Old: Ma/rtt �� Y S-S- --- <br /> Sample 14 Sample t5 Oate�TrnCoEainerl Samplel `' Pce- 19 ;� Requested Testing ?Q Condition on 21 Disposal 22 <br /> Number Descri tion/T s Collecta Volume servetive Program Receipt Record No. <br /> 14 012,177- 1300 <br /> LR TEA, <br /> o!�! 9z 171 S ��R iii qg • p . Ail- <br /> 94 T <br /> f- ' ' t' a <br /> �h of zl qz zl°a °i/u <br /> ♦ w i 1n 9 Q <br /> WOO [ 1 <br /> 'J r, �i ,• is 1 MH <br /> tat (n <br /> •r � _ I t T• l3 n1 ra N <br /> Special Instructions: 29 r ' <br /> Possible Haz rd Identification: 24.� :Sample Disposal; 2s <br /> Nqn-hazard Flammable ��1 Skin Irritant: lJ' ' Poison B i�. Unknown �1�," P ''Return to Client 1 l : Disposal by L Archive (mos.) <br /> Turnor n Time Required: 26 , : , DC Level:27 <br /> Normal A RushIJ <br /> 1. Relinquished by 2t3 Dater! ;-2- Z 1. Received by:2S Date: <br /> �A�,,l�f T �]" , I [' C <br /> fSignawm/A[fitiatianl ��'"'��"i 1 .J. [. �0/ Time:i+ �, i�ignettq�/Affir<arlary� L •i <br /> i Timer <br /> '�:J n a - ❑ <br /> 2. Relinquished by Date: `' 9.'Deceived LL[�--..' r Date: — --_ <br /> (Signature/Atfirietionl Time:-' [ l�neture/ARifi�Or,]—)77 Time; <br /> 3, Relinquished by i_, Date:''' � �� 3.;,Received by Date:' <br /> [Signature/Alfilietian] � Time:', t /Affiliatiu, �� ,Time:_ /a/p <br /> i• 1 <br /> Comments:29 GJ. <br /> RI <br /> •_ <br /> it• t� f• i•i• t• nommoo6mm Mce. MI <br />