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Chain of MEMO <br /> Custody Record Severn Trent Laboratories, Inc. <br /> S7t-0.124 {0700} I Chain of]CuCstod Number <br /> C(ierR ( r P-701,Ma �+ � 025 5 6 52 <br /> r ! <br /> 1 t Tele hole lVu 6' {JArefa ROY?Number Lab Number <br /> Address Page of <br /> Site Contact Lab Contact �1 Analysis(Attach list if <br /> Cit tstate ZIP Codi /� E r mores ace is needed <br /> Y <br /> t prof ct Name anc� c t o ��tate} CamerlWaybill Number <br /> l 'til co � St ('x,14�7 Special Instructions/ <br /> s� <br /> I �s <br /> TConditions of Receipt <br /> ontract/P.urchasp Order/Qu e o J , <br /> Containers& <br /> `C <br /> t ` I� t` � �,��}��� Matrix Preservatives <br /> Z <br /> Sample 1 D No and Description Dat Time m o - a y o o G <br /> (Co tai for epch sam !e may be combined on one line} a us cn a` x x z <br /> rs z N z <br /> J <br /> Sample Disposal __4� (A lee may be assessed if samples are retained <br /> Pos bte Hazard Identification <br /> ��❑ Non Hazard [3 Flammable ❑ Skin Irritant ❑Poison B El Urtkrto n Ret rrr•To Client '� Drsposar By Lab ❑Archwe For Months longer than 3 months) <br /> 4 QC Requirements(Specify) <br /> Tum Around Time Required <br /> ❑ 24 Hburs ❑48 Hours ❑ 7 Days ❑ 14 Days ❑ 21 Days ❑ Other_ _ Date Time <br /> Dat6 f, Time, 1 Received By _ <br /> �. � <br /> 1 Relinquished By 1���lJ r � Ge/ �s� �_; +•,: <br /> t <br /> Date <br /> Time 2 Received By Date Time <br /> 2 Relinquished By <br /> i <br /> Date Time <br /> Date Time 3 Received By <br /> � 3 Relinquished By <br /> I <br /> Comments <br /> i <br /> DISTRIBUTION WHITE-Stays with the Sample CANARY-Returned to Client with Report PINK Feld Copy <br />