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1LITYANALYTICAL f uG L/1G WG GS <br /> _ �ORATORIES.INC. <br /> CHAIN OF CUSTODY RECORD AND AGREEMENT TO PERFORM SERVICES LIMS <br /> Project# Purchase Order# EILGN 110 THIS AREA FOR LAB USE ONLY <br /> O' }�^ One Innovation Drive,Suite C 090 Caterpillar Road Lab# Page of <br /> Alachua,FL 32615.9586 Redding,CA 96003.1412 <br /> Project Name (904)462.3050 FAX(904)4621670 (916)244-5227 fAX{9161244-4109 F,S�2C, <br /> l &t VVI , M1,91 ❑LMG ❑LKW Client Service Price Source <br /> 2567 Fairlane Drive Canviro Analytical Laboratories,Inc- <br /> Company <br /> na A P Q S <br /> Company Name Montgomery,AL 36116-1622 50 Bathurst,Unit 12 <br /> �� C-_ <br /> {334}271-2440 FAX(334)271-342B Waterloo,19) 7.2aS75 Ontario, <br /> ofAX 519)t747-3806 <br /> DOE Acct Code Test Group <br /> Project Manager or Contact&Phone# Report Copy to: ANALYSES REQUESTED <br /> 11 <br /> P.t twkIZID F i S A — il <br /> jC�Elu) 14`4 F <br /> 6 NIA W � � 1~ —inProject Code Ack.Gen. <br /> Requested Completion Date: 511010 Sample Disposal: 8 <br /> DI Return 0 1 Q a <br /> AlSCo ❑ NW W <br /> T g L4J � W V LtMS Ver Login Mull. <br /> Type Matrix A3 <br /> C G W S k + `Z, 1;? ty � COC Review <br /> Sampling A O CLIENT SAMPLE ID QC ID <br /> -1 LAB 1 LAB 2 <br /> B E L (9 CHARACTERS) (3 CHAR) s p�. SAMPLE REMARKS ID ID <br /> Date Time R r <br /> 8 A 63 1_ _ -8_ D _.__ ._ <br /> `- <br /> 10 <br /> -- -- --- <br /> Sampled By A Title IPiaaoa syn and Pr" c L DateJ1•Im 169% Relinquished By tPiease sgn and Pont twnal Date/Time HAZWRAPINESSA: Y N <br /> is l'1 a�D E L 16- EDATA: Y N <br /> R Ived By lP ease spn and PoM name D t hla Relinquished By IPieaw SO4 and P'+µmaul patefrlme <br /> OC LEVEL 1 2 3 OTHER <br /> Received By IPteaSe s r aM Pnnl nanlel at me Relinquished By m6asa a p aro 001 name) DaI&Time <br /> H lea <br /> Received By IpleaasgnanaMnimnll DatelTime Shipped Shlpping9 Custody <br /> TOM Ex Other seal N <br /> `f~ <br /> G <br /> atch Remarks: <br /> tructions and Agreement Provisions on Reverse Side DISTRIBUTION.original• LAB,Yellow- LAB,Pink-Client <br /> REV 5195 LAB FORM 340 <br />