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i I• <br /> Chain-oliCustody Number <br /> I 1W <br /> SECQR Chain-of Custody Record4J <br /> Field Office 077 <br /> Additional documents are attached, and are a part of this Re*;rd <br /> /LY, Job Name � +�' <br /> Addresses/� <br /> Location <br /> Analysis Request <br /> Project#�T.7��� �?-��Task# <br /> Project Manager hY <br /> Laboratory 14 00 m m x <br /> Turnaround Time _ cc <br /> _ <br /> 9 °� <br /> 9� � -9CO WU � �v <br /> m Q <br /> ` <br /> O <br /> CO o yo Ca 00E tSamplers Name -oo E W0m OD oN -a 23 Sampler's Signat re Ln E 9m z <br /> Comments/ <br /> Sample ID ime Matrix a z f- Instructions <br /> Special Instructions/Comments Relinquished by Received by Sample Receipt <br /> Sign - Sign Total no of containers <br /> k Print Print Chain of custody seals <br /> Company Company Rec'd in good condition/cold <br /> Time 7. U/ Date f , Time Date Conforms to record <br /> Relinquished by Received by Client <br /> Sign— Sign ' d e. <br /> �.� <br /> rint Print 44 4_rizy Client Contact <br /> C mpany Company- <br /> Time,,, Date Time "27 Date JFv i a Client Phone <br /> PW 2 Date 6? 7 /IfIr-1 Page r of I <br />