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err it r r� rr r Ire r r� I�r IIr rl M <br /> TzoNA1. ANALYSIS REDU� AND Referenceocument o <br /> ® <br /> TECHNOLOGY <br /> CORPORATION O CHAIN OF CUSTODY RECORD* Page 1 of A <br /> � <br /> Project Name/No t !• zt- !�9/l Samples Shipment Date ? 3-�{~ Bill to Cc2p• <br /> Sample Team Members 2 -:3> AVNs =A'S <br /> Lab Destination <br /> M A2T�1`1EZ C� <br /> Profit Center No __ 4/ _ _ _ Lab Contacts <br /> 4 KiK 7 12'�.1�9itK,?Q,(5to)3Ttfia6 <br /> _ _ , Protect Contact/Phone 10 <br /> Project Manager <br /> Report to <br /> Purchase Order No 6__ Camer/Waybill No 13 - <br /> m <br /> Required Report Date <br /> • • i • <br /> m <br /> Sample 14 Sample 1 DRUMM*16 Container mple 1 Pre- 19 Requested Testing 20 Condition on 21 Disposal 22 <br /> Number n/T Collected T Volume servatnfe ram R Record No <br /> m <br /> 0.3 692A-f&) Gawu�a L--Z �d5 Vo04 tbti2 Not- �T-R4(G)/F X <br /> r £ iR-UHk <br /> _ 5D <br /> CL <br /> o <br /> o3?a9z�-rwZ �rzoc�nS�wAi� rL�O W4 Vr.- 1-160 —T�(&) 15TV <br /> ' I$ W <br /> C4 tr 7 ro <br /> m <br /> Cr <br /> m <br /> 0 <br /> Special Instructions 23 3 <br /> Possible Hazard Identification 24 Sample Disposal 25 ° <br /> Non-hazard' Flammable Skin Irritant 1J Polson BJ] Unknown IJ Return to Chenfi� Disposal by Lab Archive (mos ) <br /> Turnaround Time Required 26 DC Level 27 <br /> Normal• Rushy F'I-.1— II IJ III IJ ProectSpecific (spec ) <br /> 1 Relinquished28 Date _ 3= 31 -qZ- 1 Received by 28 Date <br /> [Signature/Affidabon) Time (Srgnature/Affikrabon) Time o <br /> 2 Relinquished by Date _ 2 Received by Date fn <br /> [Sign ure/Affiliation) Time [Srgnature/Affibetionl Time <br /> 3 Relinquished by Date _ 3 Received by Date <br /> [Srgnatun;/Affiharion) Time [signature/Affiliation] Time <br /> Comments 2s <br /> MCA 9115191 <br />