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- 4AWLYfICAL �� q <br /> ~ ORlFS,1NC. <br /> CHAIN OF CUSTODY RECORD AND AGREEMENT TO PERFORM SERVICES <br /> Project# Purchase Order* ❑LGHRp THIS AREA FOR LAB USE ONLY <br /> 3O, 07- one innovation Drive.Suite C 5090 Cafarp"Road Lab# Page of <br /> Alachua,FL 326166-9586 Reftng,CA 98003.1412 - <br /> Project Norms (904)462.3050 FAX(904)462-1670 (916)2445227 FAX(916)244-4109 <br /> Dt 5 l T$ (,6-•V . m��t tTRl+ r DLMG ❑�Kw <br /> 2567 Fairlane Drive Carniro Analytical Laboratories,Inc. Client Service Price SOUrO@ <br /> Company Namea x AL 036116.1622 50 Bathurst,Unit 12 A P Q S <br /> (334 <br /> {334}271-2440 FAX(334)271-3428 Waterloo,Ontario,Canada N2V 2C5 <br /> (519)747-2575 FAX(519)7475806 <br /> Pro Manager or Contac)It<Phone a6- I Report Copy to: ANALYSES REQUESTED Acct Code Test Group <br /> WOW 0 <br /> Date: Site 1D Sample Disposal: F Project Code Ack.Gen. <br /> Dispose Rwmn <br /> E] h <br /> +SIV N <br /> tAatrtx A Z,� LIMSVer Login Mutt. <br /> TYPOSampling Y A T O CLIENT SAMPLE ID QC A e a COC Review <br /> Dots <br /> TimeP 9 R L (p CHARA1. CTERS) �3 R) s N SAMPLE REMARKS LAB 1 LAD 2 <br /> 61 11V <br /> 5t � <br /> 1�th <br /> b� yS <br /> � W <br /> mpledBy&TgM, , iaNaeeoipnerd ronel Relinqu By andvdmM *E1:1A:TA: <br /> HRAPINESSA: V N <br /> UOYN <br /> L1 b k <br /> RBpiYed By Irraaerr.lp�ad piner!tAe) Dfitemhm Relinqul By ( wwendpunre ne) Da V N <br /> Received By larft rapn and pinrnw-1 DatelTlme Relinquished By (P'--S*end pun nems) DatelTime <br /> QC LEVEL 2 3 OTHER <br /> _ tee <br /> Raaslwed By (Prase sign No pit nano) Daterrime Shipped Vls Shipping iF <br /> UPS Fed-Ex Other Seal Tem <br /> Batch Romanis: <br /> Instructions and Agreement Provisions on Reverse SW DISTRIBUTION:Original- LAB,Yellow- LAB,Pink-Client <br /> REV 5195 LAB FORM 340 <br />