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A in nic Traffic Report <br /> Case I <br /> PA United States Environmental Protection Agency & Chain of Custody Record <br /> Contract Laboratory Program (Fpr Inorganic CLP Analysis) <br /> 1 Project Code Account Code 2 Region No Sampling Co 4 Date Shipped Carrier 6 Matrix 7 Preservative <br /> (Enter (Enter <br /> in Column A) in Column 0) <br /> Regional information Sampler(Name) Airb+Il Number <br /> 1 Surface Water 1 HCl <br /> 2 Ground Water 2 HNO3 <br /> 5 Sht To 3 Leachate 4 HaOH <br /> SO <br /> Non-Superfund Program Sampler. P 4 Field QC; H2SO4 <br /> 5 Sod/Sediment 5 Ice on 7 <br /> 3 Purpose Early Action Long Term 6 Oil(High only) 6 Ice only <br /> CLEM Acton 7 Waste(High 7 Other(spec! <br /> Site Name Lead PA FS only) in Column D <br /> SF REM RD S Other(specify N Not preserved <br /> PRP Rl RA in Column A) <br /> City,State Site Spill ID ST Sl O&M ATTN <br /> FED HESI HNPLD <br /> CLIP A B C D E—RAS Anal sis F Gation H ! J K <br /> Sample Matrix Cvnc Sample Preser y N ono onh Traci+kmgl Numbfer Lotcat on Year/Time 'LP Organic Sample <br /> Qualifier <br /> Numbers (from Low Type vative c) or Tag Numbers Identifier Sample Sample No =&anx Duplicate e <br /> (from Box 6) Med Comp) from m m p � 6 °-°imale <br /> High Grab Box 7) 2 Z 'a Collection R ftrm e <br /> labels) Other o+r+er T° o 13 <br /> o P£Na�ocsample <br /> p r U Z U. a U <br /> Chain of Custody <br /> Shipment for Case Page Sample(s)to be Used for Laboratory OC Additional Sampler Signatures <br /> Seal Number(s) <br /> Complete?(YM) <br /> Of <br /> GmAIR!OF CUSTODY RECORD <br /> Relinquished by (Signature) Date/Tim Received by (Signature) Relinquished by (Signature) Date 1 Time Receroed by (Signature) <br /> I <br /> Relinquished by (Signature) Date 1 Time Received by (Signature} Relinquished by (Signature) <br /> Date 1 Time Recelved by (Signature) <br /> Relinquished by (Signature) Date 1 Time Recelved for Laboratory by Date!Time Remarks Is custody seat/intact YMlnone N <br /> (Signature) 4 i <br /> Region Copy Pink-CLASS Capy EPA Farm 9110-1 SEE REVERSE FOR ADDITIONAL STANDARD INSTRUCTIONS <br /> DISTRIBUTION Green <br /> "SEE REVERSE FOR PURPOSE CODE DEFINITIONS <br /> White-Lab Copy for Return to Region Yellow Lab Copy for Return to CLASS 37292' 0 <br />