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i <br /> i <br /> CHAIN OF CUSTODY RECORD <br /> Date Page_ of <br /> CLIENT <br /> ADDRESS PROJECT MANAGER <br /> Samples Intact Yes No <br /> PHONE NUMBER County Seals Intact Yes No ' <br /> Sample Ambient Cooled_Frozen <br /> PROJECT NAME SAMPLERS: (Signature) Same Day 24 Hr. <br /> Regular 48 Hr. <br /> SAMPLE LOCATION SAMPLETYPE NO OF SUSP. TESTS <br /> NUMBER DESCRIPTION DATE TIME WATER AIR SOLID CNTNRS CONTAM. REQUIRED <br /> Relinquished by: (Signature) Received by:(Signature) Date/Time I hereby authorize the performance'of the above <br /> indicated work. <br /> Relinquished by: (Signature) Received by Laboratory for analysis: Date/Time <br /> (Signature) <br /> Special Instructions: <br /> DISTRIBUTION:White with report.Yellow to AL, <br /> Pink to Courier <br />