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1 of � � <br /> Chain-of Custody Number <br /> SECOR Chain-of Custody Record /pQ S�3 <br /> Reid Office 5 i�Gy R <br /> Additional documents are attached, and are a part of tNs Record <br /> 173q 3 '��' sf t,cf Job Name T/�`'�E O/L <br /> Address — <br /> e r.M e,,-Pa [h Location <br /> o /C e 4n <br /> Project # 44a -c* -of Task# LyCa Z Analysis Request <br /> Protect Manager �at.n Qe wQ1- r <br /> Laboratory c r N ' N <br /> Turnaround Time Sia nd&rj --- - c C <br /> Cj <br /> 41 _ R�U U N <br /> Sampler's Name w o �� ro o o °- <br /> E � E m U� b'r c.- on _2� w aT n <br /> Sampler's Signature �_ �, �, a c°m a in CO 'm Q in -' Z, a <br /> U 4 o 4 o a,. 2o o N co o civ i o o v U Comments/ z <br /> Sample ID Date Time Matrix �-m w F- ¢C z� 0. a u5 r w Instructions <br /> w f,- 3 <br /> 3 <br /> x 3 <br /> Special Instructions/Comments Relinquished by Received by Sample Receipi <br /> Sign Sign --M-LZ 5a=gdsTotal no of containers <br /> Print � Print SoWer-:5 Chain of custody seals <br /> Company 5-`JfoR Company CXcelchet-! Recd in good conditionlcoid <br /> Time •' Date " Time /D Date Conforms to record <br /> Relinquished by Received by <br /> Sign Sign Client <br /> Print Print Client Contact <br /> Company Comp <br /> Time Date e Date Client Phone <br /> SECOR CUSTREC Rsv 119s <br /> Date __ 1 1 Page of __ <br />