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INTERNATIONAL s � '� <br /> TECHNOLOGY ANALYSIS REQUEST AND Reference Document No <br /> CORPORATION J 1 re CHAIN OF CUSTODY RECORD* Page I of <br /> Project Name/No 1 E ' r ' l �7 r° 1 Samples Shipment Date 7 U r- r 'd r Bill to 5rt <br /> r , <br /> Sample Team Members ? t 4- Lab Destination <br /> Profit Center No 3 Lab Contact s - <br /> �. <br /> Project Manager4 'I' Project Contact/Phone �� ,/r <br /> )o <br /> Purchase Order No r c;,� C� Carrier/Waybill No 13 _ _ Report to <br /> Required Report Date <br /> a <br /> Sample 14 Sample 15 Date/Time 16 Container) Sample) Pre. 19 20 21 <br /> Number Descry tion/T pe Collected T e Volume servatnre Requested Testing Condition on Disposal 22 <br /> Program Receipt Record No— <br /> file, <br /> a <br /> 11 ! �� ` l � � (. r , r � IT / � _��;�/.,/•i Cr,l J �(`� t '` rr"•,/' !J'��r � ! 1 /' i 4 ,� e i" �' f7/r o <br /> C lI <br /> I II <br /> 11 /b 11 f! r3. <br /> Y <br /> r <br /> f <br /> Cn <br /> r � + <br /> r f N <br /> r <br /> w <br /> 1 f x <br /> 0 <br /> Speciallnstructions 23 <br /> Possible Hazard Identification 24Sample Disposal 25 0 <br /> Non-hazard 7J Flammable _J Skin Irritant 1J Poison B J Unknown hJ Return to Client`_J Disposal by Lab Archive [mos ] <br /> Turnaround Time Required 26 QC Level 27 <br /> Normal ;J Rush j I ,J fl J III i„J Project 5 eciliic (specify) <br /> 1 Relinquished by 28 Date rt <br /> (Signaturi/Affiliation) 1 Received by 28 + Date <br /> !/ 7 1' Time ' tZy 1 [Signature/Affiliation] �� (� r_ <br /> Time <br /> 2 Relinquished by Date 2 Received by Date ZI <br /> (Signature/Affihatton] Time [Signature/Affiliation] Time <br /> 3 Relinquished by Date 3 Received by Date <br /> (Signdture/Affiliation) Time [Signature/Affiliation] Time <br /> Comments 29 <br />