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ustod ecord -� <br /> QUA-4124 0797 <br /> Client Protect Manager Datej Chain ofGustodyNumber <br /> L4 M - `� ~- I-z G /-7 42�l 26822 <br /> Address Teleph a tuber(Area Code)/Fax Number Lab Number <br /> Tf {f] $ � OC7 Page—f— of <br /> C Stat 'tip ode Site Contact Lab Contact Analysis(Attach list if <br /> 8 1 mores ace is needed <br /> Project Name Camer/Waybill Number y l� <br /> L ; T Specrallnstrucfrons/ <br /> Contract/Purchase Order/Quote No Matrix Containers& s- Conditions of Receipt <br /> 8 Preservatives <br /> Sample l D No and Descnptton pate Time - a r°n o o �o <br /> (Containers for each sample may be combined on one hne) <br /> —� <br /> ' tl <br /> ( 'D <br /> Possible Hazzard lden0cation Sample Disposal <br /> El <br /> Hazard ❑ Flammable C3Skrn irritant ❑Poison B ❑ Unknown 1-1 Refum TO Client ❑ Disposal By Loh ❑Archive For Months (A lee may be assessed if samples are retained <br /> Longer than 3 months) <br /> Turn Around Time Required QC Requrrements(Specify) <br /> ❑24 Hours [:148 Hours ❑ 7 Days ❑ 14 Days ❑21 Days ❑ other <br /> I Rehnqu �y Date -,me t Received 8y Date Time <br /> 12-/SD-4 1 1 1 1 , <br /> 2 R rn hed By Date Time 2 Received By Date Time <br /> 3 Relmqurshed 8y Date Time 3 Received By Date lime <br /> r <br /> Comments <br /> DISTRIBUTION WHITE-Stays with the Sample, CANARY Returned to Client with Report PINK-Field Copy <br />