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i <br /> Chain-of Custody Number <br /> , CQR Chain-of Custody Record <br /> Field Office 0-77 — 5. Additional documents are attached, and are a part of this Record <br /> Address W,-7 1k,kew,.t tA,A( v t Job Name <br /> 7�j Location 203�( Vl(5O 6ceA,�AI�A( <br /> �a C A <br /> �� Tasl # L 6 3 M Analysis Request <br /> Protect# ���L,����a, � ,� <br /> Project Manager r� r <br /> Laboratory . n e_ rJ� co y <br /> i N 'i r N U fR i <br /> Turnaround Time <br /> N N i fII <br /> ro oO a - j p� fA C v c <br /> LD m cU J-- <br /> ON <br /> V N U <br /> Sampler's Name " �c�r • a - <br /> o W ino -- yo <br /> Sampler's Signature Q (Gm ON 0o °N m 0 N r <br /> a� my °,`- E n mw -,a o;� a K E <br /> Sam le ID Date Time Matnx a o a o a o m cv m o o a r 0 Comments/ , <br /> x ao ao f- a co x w u1 cc a �,. a. Instructions z <br /> M�J�1 16 k 1tb {�'wV X I <br /> N1v�-1 b to t� ta' 95 i <br /> 1 <br /> > . a It) 1t IU-R, _ <br /> M\A)-Yt5 ,5 1v tb k0 §-1 <br /> MvJ-3 tv tl; I3' �C <br /> Special Instructions/Comments Relinquisl by Received b Sample Receipt <br /> Y P � <br /> Sign <br /> 9� ,� , Sign .-�-"� Total no of containers <br /> Print r~ Chain of custody seals <br /> Company �Cc Company.f �� <br /> Time_!! � Date iCl 1� .., Recd in good condition/cold <br /> TIS Date . ' <br /> Conforms to record <br /> Re4n'quhedbyf Received�by Client ' <br /> Sign Sign /, ---- <br /> Print ���, �' Print X4��"r' �� sClient Contact <br /> Company' Company <br /> Tirloe'` Date Time Date `F�� ? Client Phone <br /> a^ECOR CUMEC Rev 2199 ' z <br /> Date / / r Pa*jf of <br />