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� � . .�. ii . . i� '�.�.ii .. .■■� � r . � r r lar it � r- rr... iii-. <br /> Chain-of Custody Number: <br /> SECQR ' Chain-of Custody Record <br /> Additional documents are attached, and are a part of this Record. <br /> Field Office: <br /> Address: S �� z0 Job Name: <br /> 1_ocation: <br /> F". <br /> Analysis Request <br /> Project # S —D `0 Task# <br /> Project Manager �' s <br /> Laboratory Ste' N ti <br /> W9 C <br /> TurnarID ound Time a m� �^ <br /> CU 7 Q41 <br /> LO <br /> .� <br /> N Q.Q7 Q O1�' m N Ur 4. fd .0 <br /> Sampler's Name c r r W 12o`a o 0 0 ;� a <br /> Sampler's Signature o ,� ,� `� m c� .' `-' �' a , E <br /> x (L o a n V E RJ y N o-- Comments <br /> U o do a a oc� �a dc� ago ov U z <br /> Sample ID Date Time Matrix = m w co a OW m z w W CO a to r n a`2 ti Instructions <br /> f Z3-fi t/ go;; t ) <br /> � g�2 3,S' 413•Y6 � I <br /> t/ I <br /> S ecial Instructions/Comments: Retinquishe by: Received by: Sample Receipt <br /> Sign 'gn Total no.of containers: <br /> r,--r Print Print Chain of custody seals: <br /> Company Com Rec'd.in good condition/cold: <br /> Time Date '2� e D e Conforms to record; <br /> Relinquished by: Receive <br /> Sign _ Sign Client: <br /> Print - _ Print Client Contact: <br /> Co y Company <br /> me Date Time `y'' _Date t fro y Client Phone: <br /> SECOR CU5TREC Rev.1195 <br /> • Date: Z� Page__V_of Z <br />