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INTERNATIONAL REQUEST AND Reference Docs <br /> TECHNOLOGY ANALYSIS r <br /> CORPORATION [ CHAIN OF CUSTODY RECORD* Page 1 of <br /> Project Name/No S,C, ,w�ta.,T Samples Shipment Date �� " � <br /> Bill to s r <br /> Sample Team Members __ Lab Destination <br /> Profit Center Nos Lab Contact s_ �_ <br /> Project Managers g,.� Project Contact/Phone 1 � �CY— to <br /> Report 0 <br /> Purchase Order No _ Carrrier/Waybill No �3N � <br /> p 1a — <br /> Required Report Date-"��r ,, i <br /> ro <br /> Sample 14Sample Date/Timea Container Sam ie 1 19 <br /> m <br /> Pre- <br /> Number Descry tion/T a Collected T e Volume servative Requested Testing 20 Condition on 21 Disposal 22 <br /> Program Recei t Record No <br /> ! � Voo A -rPN G r, <br /> Fc G�o� Zx4d HC-L <br /> i2an <br /> a <br /> C,a <br /> Ick F� 6� �k <br /> m <br /> m <br /> Cr <br /> n <br /> x <br /> Special Instructions 23 0 <br /> Possible Hazard Identification 24 3 <br /> Non-hazard I Flammable I� Sample Disposal 25 CT <br /> J Skin Irritant f J Poison B LJ Unknown IJ Return to Client FJ Dis osal b Lab l <br /> Turnaro nd Time Required 26 OC Level 27 P Y Archl�e_� (mos )Normal 11 RushfJ �a <br /> f� 11�J lil iJ Project Specific (specify) <br /> 1 Relinquish 28 ❑ate 51 9e. 1 Received by 28 Date --� �~ <br /> (Signature/Affiliation) _ �J /�, c -z4 <br /> Time _ - (Signature/Affiliation) c/ (i 2 Relj imeRelinquished by Date <br /> (Signa6ure/A2 Received by Date 0 <br /> ffiliation] Time — <br /> (Signature/Affiliation] <br /> 3 Relinquished by Date Time <br /> 3 Received by Date <br /> (signature/Affiliation) Time (Signatecei iLatRon) <br /> Comments 29 Time <br />