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A nic Traffic Report Case No <br /> A United States Environmental Protection Agency Chain of Custody Record <br /> ,��� Contract Laboratory Program <br /> (For Organic CLP Analysis) <br /> 1 Project Code Account Code 2 Region No Sampling Co -44—Date 6 Matrix 7 Preservative <br /> (Enter (Enter in <br /> in Column A) Column D) <br /> Regional Information Sampler(Name) Alrbdl Number 1 Surface Water 1 HCI <br /> 2 Ground Water 2 HNO3 <br /> 3 Leachate 3 NaHSO4 <br /> Non-Superfund Program Sampler Signature 5 Ship To 4 Field OC 4 H2SO4 <br /> 5 Soil/Sediment 5 Ice only <br /> 3 Purpose' Early Action Long Term 6 Oil (High only) 6 Other <br /> CLEM Arbon 7 Waste <br /> ecrf fn <br /> Site Name Lead PA FS High only) Column D) <br /> SFREM RD 8 Other (Specify N Not <br /> PRP RI RA in Column A) preserved <br /> City,State site Spill 10 ST Sl O&M <br /> FED ESI NPLD ATTN <br /> E F G H I J '{ <br /> CLP Matrix Conc Sampl Pre°er RA5 Analysis Regional Specific Station MolDayl Correspandtng Sample Field OC <br /> Sample (from Low Type <br /> vative Tracking Number Location Year/Time CLP Inorgarnc Initials a-Qualifier <br /> Numobers Box 6) High Grab �fo�n : a a c� High or Tag Numbers Identifier Sample Sample No <br /> only Collection R <br /> labels) ocher io y O m AROI ?E_Perform aOC-Svai <br /> --iVai a CIC sm W <br /> a- TOX <br /> I <br /> E <br /> i <br /> it <br /> i <br /> a <br /> c-- -a• j •;�u page 5ample(s)to be Used for Laboratory OC Additional Sampler Signatures Chain of Custody Seal Number(s) <br /> y_ ..='e" Y�. <br /> of <br /> CHAIN OF CUSTODY RECORD <br /> ae rimed r r (S g^azure) Date I Time Received by (Signature) Relinquished by (Signature) Date 1 Time Received by (Signature} <br /> Relinquished b Sr nature Date 1 Ttme Received by (Signature) <br /> Rer^qu sped by (Signature) Date/Time Received by (Signature) y ( 9 ) <br /> I � <br /> x <br /> Relsni;usshed by {Signature} 4—DatWe/ e Received for Laboratory by Date 1 Time Remarks Is custody seal intact? YM/none N <br /> (Signature) C 1 <br /> DISTRIBUTION Blue Region Copy Pink CLASS Copy EPA Farm 9110-2 SEE REVERSE FOR ADDITIONAL STANDARD INSTRUCTIONS <br /> "SEE REVERSE FOR PURPOSE CODE DEFINITIONS <br /> White Lab Copy for Return to Region Yellow-Lab Copy for Return to CLASS .aaJ7 2 <br />