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Chain of <br />Custody Record <br />OUA-4124 0797 <br />_ H7 tet'✓ �s � �5�=rib �iH�" �t 1, ��,` c� � T�{-� R��i' oR� <br />'ZO Tie- A-T7,4c /%% <br />Client <br />&i C - ®N -1-NC . <br />Project Manager <br />R O <br />Date <br />11 <br />Chain of Custody NumbV <br />51 <br />Address t <br />Tele hone Number (Area Code)/Fax Number <br />Lab Number r� <br />U �^ lltt� _ vR� su �' D� <br />I� o <br />®%vl'b <br />Page of -� <br />City <br />State <br />Zip Code <br />Site Contact <br />Lab Contactnalysis <br />^' <br />(Attach <br />list if <br />2. Received By V <br />S <br />C <br />r 7 <br />.Zn! <br />mores <br />ace is needed <br />3. Relinquished By <br />Date t Time <br />3. Received By <br />a Date <br />Time <br />Project Name <br />Carner/Waybill Number <br />Special Instructions/ <br />Conditions of Receipt <br />Contract/Purchase Order/Quote No. <br />Containers & <br />Matrix <br />Preservatives <br />1 <br />4 - <br />Sample I. D. No. and Description <br />for <br />Date <br />Time <br />g <br />_ <br />(Containers each sample may be combined on one line) <br />W <br />O <br />ry` <br />�' .... G <br />C. <br />S P <br />I <br />XXX <br />PL <br />FL "'"XXX <br />< -i— <br />Possible Hazard Identification <br />Sample Disposal <br />(A lee maybe assessed it samples are retained <br />❑ Non -Hazard ❑ Flammable ❑ Skin Irritant ❑ Poison B ❑ Unknown <br />❑ Return To Client ❑ Disposal By Lab ❑ Archive For Months longer than 3 months) <br />turn Hrouna time rregwrea <br />U(; Hequirements (Speaty) <br />❑ 24 Hours ❑ 48 Hours <br />7 Days ❑ 14 Days ❑ 21 Days ❑ Other. <br />1. Relinquished By <br />Date <br />Time <br />1. Received By <br />Date <br />Time <br />2. Relinquisheil By <br />Date I <br />Time <br />2. Received By V <br />DIle <br />Time <br />3. Relinquished By <br />Date t Time <br />3. Received By <br />a Date <br />Time <br />Comments F A X RCS V I- 1 -S -TO <br />DISTRIBUTION: WHITE - Stays with the Sample; CANARY - Returned to Client with Report; PINK - Field Copy <br />