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CHAIN OF CUSTODY NO.055472 Page idr <br /> CONSULTANT'S NAME ADDRESS CITY STATE [ ZIP CODE <br /> 16:3, >I k <br /> SP SITE NUMBER ORNER ADDRESSICITY CONSULTANT PROJECT NUMBER <br /> CONSU A T PROJECT MANAGER PHONE UMBER FAX NUMBER CONSULTANT CONTRACT NUMBER <br /> � Io / 5fI�. � Iia �- <br /> SP CONTACT BP AD ESS PHONE NUMBER FAX NO <br /> LAB CONTACT LABORATORY ADDRESS PHONE NUMBER FAX NO. <br /> �s <br /> SAMPLED BY(Please Pri Name) SAMPLED BY ignature) SHIPMENT DATE SHIPMENT METHOD <br /> AIRBILL NTJMIER <br /> TAT: ❑ 24 Hours E] 48 Hours ❑ 1 Week Standard 2 Weeks ANALYSIS REQUIRED g Cal �� <br /> COLLECTION CONTAINERS PRESERVATIVE <br /> SAMPLE DESCRIPTION DATE MATRIX -� COMMENTS <br /> SOIWJATER TYPE LAB -TY'1a " <br /> COLLECTION NO• (VOL.r SAMPLE# S <br /> TIME �r <br /> 7 11,16 fr <br /> L <br /> �4 p <br /> ADDITIONAL COMMENTS <br /> RELINQUISHED BY/AFFILIATION DATE TIME ACCEPTED BY/AFFILIATION DATE TIME <br /> SQ <br /> 5 <br /> CLV-16722 Distribution: White-Original(with Data) Pink-Lab <br /> Yellow-BP Blue-Consultant Field Staff <br />