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0X01 =003MZME07 AID Reference Document No. 5 7 210 3 <br /> the 11% <br /> Ogroup C MA2\1 ©F M2 MV Q!CZQM* Page 1 of <br /> Project Name/No. 1 �- 1 f �q19 6 Samples ment Date 7_ _ Bill to:5 _:J__ 'T.__C-6r`'`F__ <br /> 2 [. dS0 f/ 8S /�O/-! <br /> Sample Team Members_ b Destination _T _ Yti - <br /> s <br /> I ah root-.rt- <br /> 4 Sl�.l d [ATNt?,yP 12 --.�Z ----- a 7� —_ <br /> Project Manager Project Contact/Phone =ZSR=� <br /> _7— _ � Report to: <br /> �a�- ^� 'aQ� � <br /> Purchase Order No.s Carrier/Waybill No. 13 <br /> — - -- <br /> 0) <br /> Required Report Date 11 - - _ -- ' __ _ _ <br /> Sample 14 Sample 15 Date/Time16 Conteina rl790mp,018 Pro- 19 Roquoatod Tooting 20 Condition on 21 013posal 22 rn <br /> L3lumlrar Descrlpdon/Tylm Collected Tyg Volume eor uatho Pronrom Rocalpt Record Wo. <br /> S,S. 11 f TPN—} i�co <br /> M _oa o I u r`'a rte- MTS( loin <br /> F -TSA.TA <br /> CL <br /> -'7 0 <br /> Z - 3v I�sv <br /> sat <br /> ch <br /> r M <br /> u rrb�ri wVe c� ro l 1�p 1{G tCr <br /> - <br /> -2 vk1 - q r� /s3� 3lz yo u <br /> 0 <br /> 0 <br /> 0 <br /> Special Instructions. 23 3 <br /> 24 Sam le Dis osal: 25 <br /> Possible Hazard Identification: P P <br /> Non-hazard 1J Flammable Skin Irritant Q Poison B Unknown [j] Return to Client IJ Disposal by Lab U] Archive _._ (mos.) o <br /> n <br /> Turnaround Time Required: 26 QC Level:27 <br /> Normal IJ Rush O) 1.LA II.LA III.U) Project Specific [s eci ): _ � <br /> 1. Relinquished by 28 Date: ! 6� mm 1. Received by 2a Date:- d--Oez_ Ott <br /> (Signature/Affiliation) ✓� Time: poo (s=gneaxe/Affiliation) S Time: `J ,/Q <br /> 0 <br /> 2. Relinquisher by Date:_��-f '�-a G 2. Received by Date:_—_—.__. _ N <br /> (signature/Affiliation) Time: 13 ( /AffiSandon) Time: <br /> 3. Relinquished by Date:_&� _cam 3. Received by Date:._ <br /> (signature/Atfihation) Time: (Sgnaure/Affi%tion) Time: <br /> Comments:29 <br /> - MCA 3/15191 <br />