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i • • <br /> Chain-of Custody Number <br /> SECQR Chain-of Custody Record <br /> C Additional documents are attached, and are a part of this Record <br /> Field Office <br /> Address { <br /> Job Name <br /> iR Location <br /> r <br /> Analysis Request <br /> Project#J01 v- 00 1 Task# <br /> Project Manager Y <br /> Laboratory &%_c - — o T <br /> N V ... r: <br /> Turnaround Timein M <br /> /' fl 0r - CL <br /> _ o <br /> Sampler's Name ° m Q N c o n a co n, 4 <br /> Sampler's 51 Signature—,� — m o N m o ?co <br /> N o f E <br /> _ _ <br /> 9 / S� T� = o a m y °� d in 0 ro N 4� � w Comments/ ' <br /> U 0.o ao IL a oN �o �N mo o� <br /> Sample ID Date Time Matrix s co �m 1- a C° rz a`° �'' ° Instructions <br /> x 3 <br /> fkA cA—%- K as u 3 <br /> Special Instructions/Comments Rehnquis b r. O Recei �d by Sample Receipt <br /> y ,1, , a ^ ��C9_ Total no of containers (p <br /> Sign ►u` Sign <br /> Plant �^' Print r' , 'A` � ��� Chain of custody seals <br /> Company r r Company t et C_�r,o y,r Rec'd in good condition/cold <br /> Time u' Date i Time �� l DGte !� Conforms to record <br /> '',!r x <br /> Relinquished by Received by Client <br /> Sign Sign <br /> Print Print Client Contact <br /> Company Company <br /> Time Date Time Date Client Phone <br /> SECCR GUSTREC Rey 1195 <br /> Date Page 2- of <br />