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i <br /> Chain-of Custody Number <br /> SECORIS Chain-of Custody Record <br /> Field Office t, G' wr II Additional documents are attached, and are a part of this Record <br /> Address �Cy ` � L .r{ , `# ``'< I[ ac i, Job Name ��� �< I �iL7...✓ �r <br /> r l< � 9 5617 U Location <br /> I <br /> Project# Task# II II Analysis Request <br /> Project Manager -?f'{ it <br /> I�Laboratory f< f 0) <br /> N U E2 <br /> Turnaround Time II = R <br /> CD w al <br /> a. <br /> U is <br /> /� f /7 iv cU U U o <br /> Sampler's Name a- $ <br /> ca m 4 ' U <br /> o Q co po roo 6 mn � aV m o <br /> Sampler's Signature ro Q C4 m o ° <br /> m E <br /> U S =r = ON �� Oco � E NOD f6N Ur d <br /> Sample ID Date TimeA/,- <br /> All <br /> T ¢ i v, ti a F Comments/ 3 <br /> o3 11 3oA {I Instructions Z <br /> �� II <br /> I <br /> ' II 11 <br /> �I II <br /> II II , <br /> 11 II <br /> 11 II <br /> Special Instructions/Comments Relinq Shpt b Received by Sample Receipt <br /> Sign ° �' "I__ ' <br /> Sign Total no of containers <br /> Print '���%fes `^� � Print � <br /> Cham of custody seals <br /> Compglly 7 Co any Rec'd in good condition/cold <br /> Time `17 '��_ Date �� � Time Date <br /> Conforms to record <br /> Relinquished by Received by 3t C E < <br /> Sign Sign Client Y <br /> Pnnt it Pnnt -._ i Client Contact <br /> Co ny �I Company X,'(/ A <br /> T e {f �� Date Time LG/2 Date r�� Client Phone <br /> SECOR CUSTREC Rev 2x99 <br /> ii Date / 3 Pao— of <br />