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Chain-of Custody Number <br /> SECQR, Chain-of Custody Record <br /> Field Office QAdditional documents are attached, and are a part of this Record <br /> Address l Z S D Job Name 6 7/ <br /> -f- gz 7 Location 9, 06 /71f7er,.//tP / <br /> L�, <br /> SL <br /> Project#2 Op—01 d —y3 Task# Analysis Request <br /> Project Manager 57--A-AV eo.5 y' <br /> Laboratory vim co N e <br /> Turnaround Time C <br /> z U) in U) <br /> m o a°� c <br /> Q1 �v > OV U @ o <br /> a. <br /> 16 <br /> Sampler's Name cO voo_r maE E 9N O'Or 12 or wSamplers Signature 16 _T <br /> 0 o ?N o a <br /> z _U _ ° U 10 Comments/ <br /> oa a E� yin �§ o•• � <br /> Sample ID Date Time Matrix z F_ro co W a (0 x w cA c a(0 t g Instructions z <br /> / <br /> Ar-;?Lr/—Z /V., 1 ZK Z !� <br /> mal - zi ' IizY 13 <br /> ^v- Z - Z( � 145v <br /> I4 <br /> w—Z-3/ 130o 1S <br /> _1300 X !Co <br /> iSo Aeo C�C) <br /> Special Instructions/Co meets Relinquis Recei d by Sampfe Receipt <br /> Sig Sign Total no of containers <br /> Pent G� *T S Print 1k Chain of custody seals <br /> PS Com �Lu <br /> �"�i�/T�� Company an A Y Recd in good condition/cold <br /> Iv Itp Time - - Date I-0 Time Z Dated c Conforms to record <br /> s �s ,77✓'K xv-, 771#_�F ,�/��� Relinqw d by Received y <br /> �cLL�caaft a•c.F- Sign Sign � Client <br /> 6i.�CL J'tT�s`r�o Print W / Print � W <br /> /,� �� �'y(p <br /> Company .� Company Q Client Contact <br /> �"` Time 6 Date Time I # Date Z�'� Client Phone <br /> SECOR CUSTREC Rev 1195 <br /> Date ___ I 1 Pae of <br /> 9 <br />