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Chain-of Custody Number <br /> SECOR Chain-of Custody Record <br /> Field Office 0 Additional documents are attached, and are a part of this Record <br /> Address u 1�.2. moo _ Job Name �� o 86 ;7/", <br /> 7 Location <br /> Pro)ect# -010-03 Task# Analysis Request <br /> M <br /> Project anager r" <br /> Laboratory_ c t d 1)4 00 T <br /> m N <br /> Turnaround Time /v N <br /> m 1: CAa. U 7 O2 o <br /> �$ Cd <br /> Sampler's Name GUST S w a T °i� 01 ro a oro o <br /> O m UO �o RO 4 CD m �r N <br /> Sampler's Signalur �"" O a,� a m w 2 ro rn0 ? ow 2 a <br /> U �Q ao a °o oN �o �N ivo ov ° Comments/ <br /> Sample ID Date Time Matrix s W ► �- ¢cc r (010 9-3 f0 a Instructions <br /> ol <br /> i -d— -1 � <br /> �sG aa- D <br /> rLlw-3 3 r ' i_53o <br /> 1444 y/ � pd� <br /> �/- a�- <br /> .u� -- 6 -Z i "Qr/z <br /> rvw-gl 6t z - 1?/17 --PI <br /> Nw- y- 16 -28-7112Z2so�`L 3 <br /> Special Instructions/Com ents Relinqui by Receiv y Sample Receipt <br /> 7�;560 �J/1 <br /> Sign Sign Total no of containers <br /> v r Print G�,Very- Print 1"Wr Chain of custody seals <br /> Company Company Y'vGlnP/1 Rec'd in good condition/cold <br /> v.L Time /35!S- DateI-Z-1_1Time /3—Vr Date2A_5/9_? <br /> Conforms to record <br /> Relin s ed b Receive <br /> �-,"aD 4x)eAxev4re5 (A)o y4t � Sign t SignClient <br /> dwG rc�r/? dC� M tfr Yzea Print of Print ll~ <br /> Client ContactCompanySee aaCompany Puo <br /> Time --!4�UU _ Date y Time 140 Date I L Client Phone <br /> SECOR GUSTREC Rev 1/95 I� <br /> Date _ 1 _ / Page of <br />