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No. <br />Sample I. D. No. and Description <br />(Containers for each sample may be combined on one line) <br />es P 1 (w <br />�5P 3 <br />W) <br />L <br />F L - �_- <br />Matrix Containers & <br />Preservatives <br />Date Time - <br />pedal nauucns/ <br />Conditions of Receipt <br />Possible Hazard IdentificationI <br />Sample Disposal <br />Chain ow <br />TO Tft e7ATTACH-c=P <br />S .®� <br />r <br />Custody Record <br />(A tee maybe assessed if samples are retained <br />Months longer than 3 months) <br />Turn Around Time Required <br />OC Requirements (Specify) <br />QUA -4124 0797 <br />❑ 24 Hours ❑ 48 Hours <br />7 Days ❑ 14 Days ❑ 21 Days El Other. <br />Client <br />c �Q �- <br />-NC <br />Project Manager <br />ro <br />Time <br />Datee� <br />Date Time <br />Chain of Custody Numb ] 3 -14 <br />Address <br />6 U <br />t <br />Telephone Number (Area Code)/Fax Number <br />ce(166-9 1 <br />Lab Number <br />1) <br />� <br />T <br />0R5U Ii ,�� <br />lV <br />Page of <br />City <br />State <br />Zip Code <br />Site Contact <br />Lab Contactalysis <br />(Attach list if <br />S <br />I <br />& more space is needed <br />... <br />Project Name <br />CarderlWaybill Number <br />r <br />No. <br />Sample I. D. No. and Description <br />(Containers for each sample may be combined on one line) <br />es P 1 (w <br />�5P 3 <br />W) <br />L <br />F L - �_- <br />Matrix Containers & <br />Preservatives <br />Date Time - <br />pedal nauucns/ <br />Conditions of Receipt <br />Possible Hazard IdentificationI <br />Sample Disposal <br />❑ Non -Hazard El Flammable <br />❑ Skin Irritant ❑ Poison B ❑ Unknown <br />❑ Return To Client <br />❑ Disposal By tab ❑ Archive For <br />(A tee maybe assessed if samples are retained <br />Months longer than 3 months) <br />Turn Around Time Required <br />OC Requirements (Specify) <br />❑ 24 Hours ❑ 48 Hours <br />7 Days ❑ 14 Days ❑ 21 Days El Other. <br />1. Relinquished By <br />Date <br />Time <br />1. Received By <br />Date Time <br />2. Relinquishe By <br />3. Relinquished By <br />2. Received By <br />Date 1 Time 13. Received By <br />Comments <br />FAX RcSU I-75 r o i1 G 6 9 V--3Eo <br />DISTRIBUTION: WHITE - Stays with the Sample; CANARY - Returned to Client with Report; PINK - Field Copy <br />Time <br />