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Chain of �uanferr <br /> Custody Record <br /> QUA-4124 0797 <br /> Client Project Manager Date Chain of Custody Numb e <br /> C� ¢s G�t�2c kIcec,,, X1801 <br /> Address ,, - Telephone Number(Area Co-de)/Fax Number f� Lab Number <br /> ( v/Soi.— L1 I 2 Liz 3 w 7 3V �z page==[= of <br /> City State zip Code Site Contact Lab Contac S Analysis(Attach list if <br /> 5.=-f-c-4--it �` �S Z L.�[ rr �� r � mores ace is needed <br /> Project Name CamerNVaybfll Number <br /> 3 Specta!instructions/ <br /> ContracVPurchase Order/Quote No Containers& Conditions of Receipt <br /> Matrix a Preservatives <br /> (Containers for each sample may be combined on one line) <br /> Sample 10 No and Description Dale limeQWKJ �'g V /X <br /> Lruh <br /> --a <br /> -Amw3 � �3u u1J I <br /> Fl0 <br /> r�,,�► a 7hWe5'� <br /> r�tN — Z s 2 N Ii{� GfCryVt� <br /> L4Q <br /> Mw (� <br /> C�- N <br /> L—J I I I -- I ,T- - , <br /> Possible Hazard Identification Sample Disposal <br /> (A lee maybe assessed if samples are retained <br /> ❑ Non Hazard ❑ Flammable ❑ Skin Irritant ❑ Poison B ❑ Unknown ❑ Return To Client ❑ Disposal By Lab ❑Archive For Months longer than 3 months) <br /> Tum Around Time Required QC Requirements(Specify) <br /> ❑24 Hours ❑ 49 Hours ❑ 7 Days ❑ 14 Days ❑21 Days ❑ Other <br /> I Relinquish y Date Time Received yZ4 �4 Date Time <br /> l{a LIO C L(A K <br /> 2 Relinquished ByD Ax'���� Dae V Time 2 Received By Datelime <br /> 3 Relinquished By Date Time 3 Received By Date Time <br /> Comments <br /> DISTRIBUTION WHITE Stays with the Sample, CANARY Returned to Client with Report PINK-Freld Copy it <br />