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13Vi�L� MAL U A� * �eferr hce'"ocu� tM M <br /> rnCM1AMN//gO�� CHAIN OF CU ODY RECORD Page 1 of � <br /> Project Name/No .luti� -USamples Shipment Date 7 7`Z5-f—qy Bili to 5 - <br /> Sample Team Members 2�. ,v VAj Lab Destination 8 <br /> Profit Center No 3 3 !1 Lab Contact 9 <br /> Project Managers S-G -S Project Contact/Phone 12� �rt�5�o Report to 10 <br /> Purchase Order No _ Carrier/Waybill No 13 <br /> Required Report Date 11 Ef-/�-`3- <br /> • elk HL'111101-:11: <br /> aaa� <br /> Sample f 4 Sample �' note/rime 16 Container) Sample i Pre- i 9 Requested Testing 2Q Condition on 21 Disposal 22 <br /> Number Descri tion/T Collected T e Volumeiserwatbis Program Receipt Record No. <br /> VW 1 - 1115 � � I L t-6 civ U9y5 Bei. !",cam'' ,uic� �,Q„✓ s� <br /> 06 <br /> \/�/1/a — S 1 loon ",c G' [Nil <br /> '1h <br /> �NSrLxo•-rca`r�'�. <br /> a . <br /> . r <br /> Special Instructions 23 <br /> Possible Hazed Identification 24 Sample Disposal 25 <br /> Non hazard �J Flammable J Skin Irritant J Poison B IJ Unknown J Return to Client � Disposal by LabArchive (mos ) <br /> Turnarour d Time Required 26 DC Level 27 <br /> Normal Rush J I ,J' II J III J Project Specific (specify) <br /> 1 Relinquished b Date 7-Z`7—gY 1 Received by 28 Date <br /> [Signature/Affiliation} Time (Signature/Affdiauoni <br /> Time <br /> 2 Relinquished by Date <br /> (Signalime/Affdwuoni 2 Received by paw <br /> Time (signature/Affi6atboni Time <br /> 3 Relinquished by Date <br /> 15ignature/AHdfiaGon) 3 Received by Date <br /> Time ISgneture/Aff bation) Time <br /> Comments 29 <br />