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Chain-of Custody Number, <br /> SECQR 1' Chain-of Custody Record <br /> Field Office n2,7 j 0 Additional documents are attached, and are a part of this Record <br /> Address 2)012 &1ltllol/ t_ �P'y 5 /UC)_ �k �f _-- Job Name <br /> -[o7 Location 4350 5 <br /> � <br /> ProJect# n-77,L12CA I D057 Task# Analysts Request <br /> Project Manager2aC(- <br /> Laboratory 14A o m <br /> Turnaround Time!w c a <br /> N r CQ <br /> 2, o DC7 mC7 r1 2 ro q. CJ <br /> ❑UN' m E °° � ' i `oSampler's Name L c "N -- Q oaau a— <br /> ySampler's Signature E lm <br /> ,� ,� E M <br /> CIL <br /> i0a <br /> ir_ oEai 12 ZSam le ID Date Time Matrix 11-25Hcoi­— a CD >(a co (n co a ED ^ aInstructions 3 <br /> y r.I <br /> a �k <br /> li +� <br /> Special Instructions/Comments Relinquished by Received by T,�` Sample Receipt <br /> Sign Total no of containers <br /> Print " fr✓%r . ,rte. Print Chain of custody seals <br /> Company Compan Rec'd in good condition/cold <br /> Time 16 z z Date O� Time Date Conforms to record <br /> Relinquished by �� Received by Client <br /> Sign f Sign <br /> Print i li Print D f Pq A Client Contact <br /> Comps II Company K,F 9j <br /> Time 3I 1I Date Time 1�,2L Date 0 6 v Client Phone v <br /> k K <br /> SECMCL MEC 11 If , <br /> Date 7 / / _U� Page— of <br />