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MW r <br /> nITTECHNO <br /> Up <br /> ON A ALYSIS REE <br /> � ST AND Reference Document <br /> VAMA J 6 CH N OF CUSTODY RECORD* Pae 1 of :I, <br /> 497423 <br /> 9 <br /> Project Name/No 1 ✓I>SF "2 Samples Shipment Date 7 Bill to 5 <br /> Sample Team Members 2 r• K,-P Z�5#d Lab Destination 8 N "&f 03+Lc .� <br /> Profit Center No 3 T:?- 'tI O Lab Contact 9 "�� <br /> sProject Manager4 �-•. 005$r4-4-0Project Contact/Phone 12 is <br /> Purchase Order No �^ Camer/Waybill No 13 Report to <br /> Required Report Date 11 �Sjq-� � <br /> • • ■ amolm <br /> 3 <br /> _i <br /> Sample 14 f Sample 15 pate/T "16 or 17 Sample E pre. 19 20 <br /> Number n II Velums senrative Requested Testing Condition on 21 p� 22 <br /> ram - pace Record Na. <br /> —�� o s CL /0" <br /> ,Fpm_yofpr <br /> S is `t `Z.. K ` IO ZIC rf rr IMU <br /> 5 .-1 _3 <br /> eo-C Z, r( r r &.Minna 319 06 <br /> t u0c- LIT <br /> r / <br /> -r •' t /0 C/o %( r) r r rI <br /> I 12C <br /> ir it tt <br /> "Sf�r'r.. SDoT i lr-0 • t r, tr ► f c <br /> h <br /> Special Instructions' 23 E <br /> Possible Hazard Identification. 24 Sample Disposal 25 a <br /> No"azard ❑J Flammable EJ Shin Imtant [ r Poison B Q) Unknown <br /> IJ Return to Client IJ Disposal by Lab Archive (mos ) <br /> FNormal <br /> round Time Required 26 DC Level:27 <br /> Rushy I II LJ II! project Specific (s ec ) ' m <br /> inquished Date � zr '� 1 Received b 28 <br /> m�nmraao�i Time oL e, - 6 tagn■wm/amhawn) Date, o►I ; Ti a lLdp <br /> 2 Relinquished by Date 2 Received by paw <br /> 1SWeWm/Amuatmi Time. is /Amiiet,i Cn <br /> Time <br /> 3 Relinquished by Date. 3 Received by ime- <br /> t Aftebm) Time (Spawm/Ambar m,) <br /> Comments 29 Time. <br />