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TECHNOLOGY <br /> ANALYSIS REQUEST AND Reference Document No. -�' <br /> Con.ORAnON CHAIN OF CUSTODY RECORD* �r�3 Page 1 of L <br /> Pro.ect Name/No. 1 r Samples Shipment Date 7 ` Q r <br /> 1 P P —n...7�I !_��_.-__ Bill to:�_ 7w e- <br /> 2 <br /> Sample Team Members? Lab Destination 8 /` Q ''� 11 <br /> 3 <br /> Profit Center No.. g <br /> _ Lab Contact _ <br /> 4 12 ?6/_7d7� o <br /> Project Manager Project Contact/Phone _. ..1 — Report to:P m <br /> Purchase Order No. s (S ��� Carrier/Waybill No. 13 <br /> Required Report Date 11 1� ��/ m <br /> 1 6 ki KIM:rRequested <br /> 3 <br /> CD <br /> 16 <br /> Sample 14 Sample 15 Date�me Container' Semple 1 pre. 1testing 20 Condition on 21 Disposal 22 in <br /> Number Descri 'on/T a Collected Type Volume servativeProgram : Receipt Record No. <br /> / /x°15 v 1 2 .�o yo c!/0.4 YO �C. /.ICL 8-0 <br /> . OM4 mom <br /> yLo7�39SJ o rab.4 ,,L' AfL /& -C 6901s) tj -n <br /> aft 4V�o� 39r / s- Yom cL ��oZO _ o <br /> 10VS0 7119 5- 91, %0,*c AV 11mL <br /> Ail4l3 0713 5^- z1,0m�d ,0m 1��� -�, C �s��s <br /> 04 .„ ......._ ... .. C <br /> 1y1�/ �7/,��I,S� �LzO y0rt 1/oa d .�4 IS�GL- FDLo <br /> 3 �/lovh��,.� P� zoo <br /> Special Instructions: 23 04� ` s r <br /> �c , , . L `(7- SO 6 <br /> Possible Hazard Identification: 24 Sample Disposal: 25 Cr <br /> Nan-hazard IJ Flammable J L Skin IrritantCAj -Poison B J Unknown J Return to Client❑J Disposal by LatOA Archive `" <br /> [mos.) , <br /> Turnaround Time Required: 26 DC Level: 27 U. <br /> NormaP6, Rush J LJ ILJ 111.J Prosect S ecific (specify); 5 <br /> 1 . Relinquished by 2 Date: rJ7/ 1 . Received Date:, <br /> [Signature/Affiliation( �— Tlme: (Signature/Affiliati v� <br /> Time: <br /> 2. Relinquishe y Date: 2. Received by Date: <br /> (Signature/Affiliation) Time: (signature/Affiliation) Time <br /> 3. Relinquished by Date: 3. Received by Date: <br /> {Signature/Aff kation] <br /> Time: [signature/Affiliation] Time: <br /> Comments:29 <br /> Mr-A&M91 <br />