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Chain oll" <br />Record <br />C-- l /</5"69-33 <br />Q06anterrO <br />Client <br />Fo H <br />Project Manager <br />os��T .¢s �� �� <br />Date <br />11/01X1915 <br />Chain of Custody Numbe <br />Address' <br />s <br />r%4 C STG. !� <br />Telephone Number (Area Code)/Fax Numb rA y <br />�!`� Y e v ! " <br />Lab Number <br />. <br />Page of <br />City <br />N ra <br />State <br />C � <br />I Zip Code <br />! ,-3 -- <br />s <br />Site Contact <br />Lab Con act <br />Analysis (Attach <br />mores ace is needed <br />^� <br />o 0 0 <br />�► � b, <br />list <br />if <br />Special Instructions/ <br />Conditions of Receipt <br />%®mob C <br />' <br />Project Name <br />/q R F6 v,P) <br />Carrier/Waybill Number <br />Fi— /) IZ- <br />ContractIPurchase Order/Quote No. <br />Matrix <br />Containers & <br />Preservatives <br />Sample I.D. No. and Description <br />(Containers for each sample may be combined on one line) <br />Date <br />Time <br />2 <br />a <br />y <br />m <br />4 <br />° 0 <br />� <br />x a <br />a <br />20 <br />0 <br />2 <br />- <br />1x113/11 <br />11 iS <br />C <br />- ,Z, <br />111131,01 <br />IL 32, <br />—3 <br />0119/ <br />1 "1 U <br />` <br />Tr'A <br />lv-,t- <br />M5 "ji * <br />R) j_L <br />III 191 <br />O90 <br />4 ? - S <br />.T- 6 <br />7 V t' - <br />I'Ll 1,9 <br />..._ <br />2-30 <br />IL110 <br />._ <br />Possible Hazard Identification <br />Non -Hazard ❑ Flammable ❑ Skin Irritant ❑ Poison B ❑ Unknown <br />Sample Disposal <br />(A lee maybe assessed If samples are retained <br />❑ Return To Client wDisposalByLab ❑ Archive For Months longer than 3 months) <br />Turn Around Time Required uu rrequiremenrs topecnyj <br />❑ 24 Hours 48 Hours ❑ 7 Days ❑ 14 Days ❑ 21 Days ❑ Other L eve 7-m-0 ar,.ais <br />1. Relinqu' hod By Date Time 1. Received By Date Time <br />toy; <br />2. inquished By Date Time 2. Received By ! Date i rime <br />3. Relinquished By I Date I Time 3. Received By I Date ( Time <br />Comments <br />;?&-. s dJ4 T Tc.s /G� /y .' d 1s6;o-e% <br />DISTRIBUTION: WHITE - Stays with the Sample'; CANARY - Returned to Client with Report: PINK - Field Copy <br />