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ATIONAL ' 1l, ANALYSIS REQ ST AND Reference Document N `' Q <br /> ® OMRL <br /> CATTIOION CHAIN OF CUSTODY RECORD* Page 1 of <br /> CORPOR <br /> Project Name/No die [A >(OL 70 Samples Shipment Date 7_<r BIII t0 6 --J i ���� ' �,),�'•` � � C* <br /> Sample Team Members Lab Destination 8 r-(,t tF A-V,l r It n ,l x _' r V11 <br /> Profit Center No a -,q1 Lab Contacts <br /> Project Manager Project Contact/Phone 12 v k e rReport 10 r + ,,c,,,r ) <br /> Purchase Order No 6 Carrier/Waybill No 13 __— <br /> a <br /> a <br /> Required Report Date <br /> n <br /> a <br /> Sample 14 Sample 15 Datums 16 7q67 <br /> r) Sample) Pre. 19 Requested Testing 20 Condition on 21 Disposal 22 <br /> Number Description/TypeCollected Volume sariiatire yarn Record No <br /> 97 /r err � �r'oZ N� yup i F ]C7, r IrLG16lr�at <br /> P= 111,44 Ram <br /> !y�?S a, c <br /> € I <br /> r4 ATHn <br /> cs <br /> r_ <br /> 1N <br /> 1� <br /> c` <br /> Special Instructions 23 <br /> Possible Hazard Identification 24 Sample Disposal 25 ` <br /> Nan-hazards Flammable {J Skin Irritant Polson B lJ Unknown �� Return to ChentrJ Disposal by Lab- Archive (mos ) <br /> Turnaround Time Required 26 QC Level-,e7 t <br /> Normal'- Rush[-JI W-J II U III J Project SP ecific (specify). <br /> i <br /> 1 Relinquished by 28 i Date ' w `Jz_ 1 Received by 28 Date ° l�- <br /> )Slgnature/Affifrauon] Time (Signature/Aff liauan) ��` Time D <br /> - 4 <br /> 2 Relinquished by Date _ 2 Received by Date <br /> (Signature/Affiliation) Time (Signature/Affiliation) Time a <br /> 3 Relinquished by Date _ _ _ 3 Received by Date <br /> (Signature/Affiliation) Time (Signature/Affiliation] Time <br /> Comments 29 <br /> MCA 3115141 <br />