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Chain-of Custody Number <br /> r SECOR Chain-o# Custody Record <br /> Additional documents are attached, and are a part of this Record <br /> Field Office ' � = <br /> Job Name ,r " 't <br /> Address <br /> Location = <br /> j u .��, Analysis Request,., <br /> Project# n _ Task# t <br /> Project Manager A-1 , co <br /> Laboratory K111 I1NA i Y t 'A L 9 R = j/ <br /> =O <br /> Turnaround Time l 'fie d m a g o rn2 y o <br /> m <br /> Q i m m =v °U � =° N tL <br /> wp s L�=j o o,0 m 01 C'3 d ? @ o <br /> Samplers Name A�'i'> ,lei rC ' w O a O V C 0 O i6 p ra p y O d-- d �. <br /> po E E r o mN ID iN °0 1 �N Y E <br /> Sampler's Signature v a d aul °a o N o N a o o °d Comments/ z <br /> Sample ID Date Time Matrix = r m �-R i— c 8 (0r CD U)(D a� h a'� F- Q Instructions <br /> DLIl i t J" (�4 S �ti,�r ✓ �+ <br /> Mw- <br /> Special <br /> •Special Instructions/Comments Relinq h Receiv� le Receipt <br /> y Sample <br /> Sign Sign, ' t.CI u'- ' a- Total no of containers <br /> Print v Print L_ # ' f-' l W, ,, Chain of custody seals <br /> Company °'Q- Company �i �.�t� �r�� Recd in good condition/cold <br /> Time ?c i Date - Time%y Data"t?' Esc., Conforms to record <br /> • Relinquished by Received by <br /> Sign ✓' Sign Client <br /> Print Print <br /> Client Contact <br /> Compa Comp <br /> Ti Date Ti Date Client Phone <br /> SECOR CUSTREC Rev 7196 <br /> Date Page of_ <br />