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UN- � M M M M * = M M M M M = 4r <br /> Chain of Gnstody QP"banterra <br /> Recor <br /> Environmental <br /> QUA-412 Sernces <br /> CIr,?. <br /> Protect Manager Dat Chain of Custody Number <br /> Ar 3961 <br /> , Telephone Number(Area pFaxNumber b Number <br /> _..1.LS� ^-^ � page <br /> City stg�, zip coda Site of Lae conra�r Analysis(Attach list if <br /> Cf � f mores ace is needed <br /> Project a Carder/Waybiir Number <br /> Contrad/PurMsse ordsvouote NoSpecial Instructions/ <br /> Matim Containers& Conditions of Receipt <br /> Preservatnres <br /> q r t <br /> I <br /> Sample/D No and Descnptron Date Time <br /> (Containers for each sample may be combined on one line} xN x x 2 <br /> 0910 ✓ ✓ <br /> of " <br /> M- q0 2 <br /> Possible Hazard ldenfiricabonSample Disposal <br /> ❑Non-Nazrd <br /> Tum Arou Aamma a!B! ❑Skin Irritant ❑poison 8 ❑Unknown (A fee maybe assessed if samples are retained <br /> ❑Return To Client ❑Drsposa!BY Lab ❑Archive For Months longer than 3 months) <br /> im Requirod/ / QC Requirements(Spedfy) <br /> Z❑24 04/ �y48 NO(irS ❑�7a4 ❑ 14 Das ❑ 21 Das ❑Oiher <br /> 1 Reii ufO By l Dat? Trme lRe <br /> By Date <br /> aattt e�j�7 / Time <br /> ,P einqurs B Date Time, Dale Time <br /> I <br /> 3 ReG urshed E?y Date Trme 3 Received By Date Trme <br /> Comments <br /> DISTRIBUTION WHITE-Stays with the Sample,CANARY-Returned to Client with Report,PINK-Field Copy <br />