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QUALITY ANALYTICAL <br /> LABORATORIES,INC. <br /> CHAIN OF CUSTODY RECORD AND AGREEMENT TO PERFORM SERVICES <br /> Project# Purchase Order# OLGN OLRQ THIS AREA FOR LAB USE ONLY <br /> A� ����T• �� : Alachua�ti32Drive,- 86 Re c Redd-ng,CA1lar Road 96003 1412 b# Page Of <br /> Project Name (904)462-3050 FAX(904)462.1670 (916)244.5227 FAX(916)2"-4109 Q 7(o <br /> Z AI6,4r f� ❑LMS �LKW Client Service Price Source <br /> 2567 Fairlane Drive Canviro Analytical Laboratories,Inc. <br /> Company Name Montgomery,AL 36116-1622 50 Bathurst,Unit 12 A P Q S <br /> LL (205)271.2440 FAX(205)271-3428 Waterloo. FAX(519) 806 <br /> Ontario, <br /> 2V . <br /> d,`I� L Acct Code Test Group <br /> Project Manager or Contact&Phone# Report Copy to: ANALYSES REQUESTED <br /> A <br /> Project Cade Ack.Gen. <br /> Requested Carripletton Date: SRO ID Sample Disposal F <br /> A / � mapose Retv11 m tv0 <br /> I T LIMS Ver Login Mult. <br /> Type I Matrix 1 <br /> C a w s N COC Review <br /> Samplingo R A o CLIENT SAMPLE ID QC ID ' <br /> M A T ! (g CHARACTERS) (3 CHAR) R � LAB 1 LAB 2 <br /> P B E L S \ SAMPLE REMARKS ID ID <br /> Date Time R <br /> fZaS X. rJ <br /> _ <br /> ^ . <br /> ,46 -- <br /> x'. <br /> pled 6 isle ea no") 0 efrimeReli Ish na prinr name] D Mm 17V HAZWRAPMESSA: Y N <br /> 'O Z ,6n I z EDATA: y N <br /> Received By - 1Prauu sign and 1 Da e!Tlme 'Rellnqulsh y' tpreasa r name] at ime <br /> © DateMme. Relinquished B Pr 'se ane prior name] Date117ma QC LEVE 1 2 S OTHER <br /> O <br /> Received 1Ptaasaa imname> q y t <br /> H Ice <br /> R el By iea i nun DatelTime Shipped V Shipping# Custody E <br /> UPS Fad-Ex Other Seal Tem L <br /> Balch Remarks: <br /> Instructions and Afrreerrtenif Provisions on Reverse Side DISTRIBUTION:Original- LAB,Yellow; LAB,Pink-Client <br />