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TtNATIONAL ANALYSIS RE�JEST AND '`��'�' ! r' a erenCe Document Ta�.HI3OLOGY <br /> CORPORATION CHAIN OF CUSTODY RECOR D Qs' Page 1 of / <br /> 7 <br /> Project Name/Noah��1r � �oa Samples Shipment Date S__ r 9 _ B(II to 5 _ / __ <br /> Sample Team Members 2 L1n✓s__ rigS Lab Destination - -- -- -- - - - - - o <br /> Profit Center No 3. 3L� 1 '�-► Lab Contact <br /> Project Manager4 t- �P`�I RS Protect Contact/Phoned F� �s��3 �i-4 f � 3 <br /> — —f---- Report to 10 - r- a <br /> Purchase Order No 6 _ Carrier/Waybill No 13_ Lo &� N <br /> Required Report Date 1� � - `� s "'� ''•"`��� C!f 3 <br /> � M <br /> Sample 14 Sample 15 Date/rime16 Container!1samplal pre. 19 Requested Testing 20 Condition on 21� Disposal 22 in <br /> Number Description/Type Collected Type Volume servatme Program Receipt Record No <br /> ,�L L C TPH-D� H-� Ry ave <br /> P-v5b19S-o l <br /> 5101 r 7700 N� s <br /> S- <br /> �200 i <br /> -05-014s-03 <�071L. S�1-f� <br /> CLn <br /> 0 <br /> IP oso cgs-04- <br /> Cr <br /> n <br /> a <br /> 0 <br /> Special Instructions 23 <br /> Possible Hazard Identification 24 Sample Disposal 25 ° <br /> Non-hazard 'J Flammable J Skin Irritant J Polson B J Unknown Return to Client J Disposal by Lab J Archive <br /> (Mas J <br /> Turnarq4nd Time Required 26 OC Level 27 U <br /> 'Normal Rus J <br /> 1 Relinquished N8 Date /fS_ 1 Received b 2e - — - v r'q <br /> (Signature/Affiliation) (f{ j y�� Time ��3D (Signature/Affihation]y Date LS <br /> Relinquished b Date __ Time <br /> 2 Relin <br /> q Y _ _ _ _ 2 Received by r Date <br /> (Signature/AH1icaUon] Jime (Signature/Affiliation) <br /> Time <br /> 3 Relinquished by Date _ _ 3 Received by Date <br /> (Signature/Affclration) Time (Signature/Aff l,atron) <br /> Time <br /> Comments 29 <br /> MCA 3!15191 <br />