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Cham`of Custody Number <br /> SECOR Chain-of Custody Record <br /> Field Office 5e,L� e_4U 1 0 Additional documents are attached, and areia part of this Record <br /> Address 3�,l`I 1�; s ��c�a ' 1 16 Job Name — V,/(A, $-�r�+ <br /> Ccs CA 9-567dil Location <br /> i r <br /> Project# 17CL T)-70 0Task# (2 66 i Analysis Request <br /> Project Manager r CoA V" <br /> Laboratory <br /> Turnaround Time r o <br /> ` m a cU 7 OU U " r o <br /> Sampler's Name AfaJ� kao. <br /> a.o U o 0 0 o o o y <br /> cv R m . o <br /> Sampler's Signature E o m N 00 °a 6 0 Y,CO <br /> Sample ID i i-o a °o o N Q m N m CL <br /> o o a °m o Comments/ <br /> Date Time Matnx �-CO �- i 0 W CO a m a r �+ Instructions Z <br /> MW- b qS <br /> Mui - b q5 k; \1 i:UU <br /> rAw-G 117 101\7 9 C5 s 1 <br /> Mme' y 11 17 10 ��� A <br /> ' I <br /> t <br /> Special Instructions/Comments Relinquished by Received by Sample Receipt <br /> Sign Sign � ' Total no of containers <br /> Print �o A CAr Print ` Chain of custody seals <br /> Company iCc,r Co an Y - <br /> y Rec'd in good condition/cold <br /> Time Date It' O tl Time <br /> Date Conforms to recd?d <br /> Relic1quished by -' Received by Client <br /> Sign - Sign 7`1 "777- <br /> Print _ 7Print Print - L '' Y''` = Client Contact <br /> Company Company'~ f`' ' ' c< < <br /> Time Date Time Date I r ' 'a" Client Phone <br /> SECOR CUMEC Rev 2x99 <br /> 0 Date �' / / �� Pag ..� of <br />