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Chain-of Custody Number <br /> SECOR Chain-of Custody Record <br /> Field Office Additional documents are attached, and are a part of this Record <br /> Address - `7lz �� Ar. -4o_c:, Job Name &---0 67/" <br /> Location — 860 <br /> 7-4:iV G <br /> Project # 7 B8S—0/0-00Task# Analysis Request <br /> Project Mana er l�aSC <br /> Laboratory <br /> Turnaround Time ICU <br /> ro <br /> iL V Q N co O <br /> 2 m `-a mV b �U U a U <br /> Sampler's Name mrd - o a o °o °1� :: ,� o m <br /> m i i °° _C °� ao � 2(a w ar <br /> Sampler's Signature -� a, �r �,� -L 00 , <br /> o .0 a o °o o c`r" �o m N m o o� 41 Comments) Z <br /> Sam to ID Date Time Matrix � 0. w ►-w a Sa a(o x-0 � a�o ti n a Instructions <br /> �/ - 6 ' I. s ore- W-1-0 <br /> � - n <br /> w�! - ib ' a/a 03 <br /> uvoid <br /> v <br /> w-I <br /> - 31 ' oz8 <br /> w- <br /> - 3,611 1016 <br /> I T1 <br /> 04 w"/ <br /> -dl <br /> �.D l0 <br /> Special Instructions/Comments Relinqugec,4by Rec AebAy Sample Receipt <br /> 1-210 Sig Sign Total no of containers <br /> +/ Print GC/hh�` e —S Print Chain of custody seals <br /> Company/ Company ���b« Rec'd in good condition/coid <br /> Time 3 S Date �l-r Time 2 S Date&Z Conforms to record <br /> 5',r.4,P1,C5 �x'r/vi_ TPS,,gMTW Relin i hed y <br /> w Receive <br /> Y <br /> ykp ax ylf-� 5 lA Ar-r*m= Sign Sign Client <br /> �.e <br /> "olrfitwal-) 4--,,v 8t' 8y6 t>, Print 0 Print _ y w yClient Contact <br /> Company r' f/ Company A;;,Mbr:,� <br /> Time 1 W) Date 1 L Time ! 4 40 Date I Client Phone <br /> SECOR CUSTREC Rev 1M <br /> Date Page of <br /> I <br />