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moll ME M M M mor <br /> ON <br /> i� �- /qp��� .C� ANALYSIS REQUEST AND �G94 Reference Document No <br /> TECHNCOMP TION CHAIN OF CUSTODY RECORD* A' Page 1 of <br /> Project Name/No _17�;- yIM'LO—Samples Shipment Date 7 7-Z0 Bill to 5 � <br /> Sample Team Members 2 _ t��1 Lab Destination a <br /> Profit Center No 3 =r2tz1i Lab Contact 9 Cn Hoc zoN T �_ <br /> Project Manager45 r--� � Project Contact/Phone 10 <br /> Report to <br /> Purchase Order No z�`�B�I Carrier/Waybill No 1$ -A <br /> Required Report Date 11 --- <br /> • • + • <br /> Sample 14 Sample 15 DateRme11CantamerlSamplei pro- 19 Requested Testing 20 Condmion an 21 Disposal 22 <br /> Number Desff!eon/jTo Collected Type Volume servauve rem pees int _ ecord No <br /> VwA <br /> r <br /> C�-r CA �— � 1►�a1 �-- <br /> �_C Z <br /> �N <br /> pa <br /> s. <br /> Special instructions 23 <br /> Possible Hazapd Identification 24 Sample Disposal 25 - <br /> Non-hazard a Flammable �-J Skin Irritant F.J' Poison B �-J Unknown Return to Client Disposal by Lab (mos ) <br /> Archive <br /> Turnargq d Time Required 26 DC,Level 27 - - <br /> Normal,d Rush i I ll!j III g Pro ect S ecific (s ec� ). <br /> 1 Relinquished b % Date _7 1 Received b _ Date _ -�� _� <br /> [aBrran,ne/raa�1 Time15r9 �Affihagor�) Time /SSd <br /> 2 Relinquished by Date 2 Received by Date <br /> is.e inrr�aaonl Time lsjeum /Arfihauonl Time <br /> 3 Relinquished by Date 3 Received by Date <br /> l5ianaaft/AftaWnl Time t114.1% l i Time <br /> Comments 29 PR'rj'��3i1�.,'„,I . _. <br /> GOOD CGNMAPPFQMM'I—Xv <br /> lAf A'It S' <br />