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Chain of STL <br /> Custody Record Severn Trent Laboratories, Inc. <br /> STL-4124 (09011 <br /> Client Proct Manager Date Chain of Custody Number <br /> LA Q-CD ceo0 1-0.%:1 1Z��$ 3 x.27146 <br /> Address Tal one umber(Area Code)/Fax Number Lab Number <br /> �.��d GIC y.?G OatiL, "7L�f�4 Q16� q-7gj--ZZcj3 page L of <br /> C�lS state zip Code Site Contact Lab Contact nNtysiS(Attach list if <br /> CA al 5 53 res ace is needed <br /> Project Name and Location(State) Cam'er/Waybifl Number 0 t% <br /> P,,S P Z$o i v J4:5+ "t Pi, 13-bc,0coACAt9 Special Instructions/ <br /> ContracWurchase Order/Ovate No. Matrix Containers& a Conditions of Receipt <br /> Preservatives ` Q 7. 4 <br /> Sample 1.D.No.and Descriptiona <br /> {Containbe co-birwd on one line <br /> Y ) <br /> {Containers for each sample ma Date Time 44-1N N <br /> y a x x x z �z W �. D1TV0� <br /> ❑1�11�-� t?,Ike Orvw X X uNF3E�COC <br /> r 4 X <br /> U) <br /> rlos .)(I X AAX <br /> �T1vJ-S Iz%S 2 X �C�G <br /> w ,µw_6 X235 2 3 X <br /> cn <br /> C>arw-� ►van 2 3 X X <br /> 0 <br /> o <br /> Possible Hazard ldentillwation Sample Disposal <br /> (A fee may be assessed if samples are retained <br /> Vt Nan-Hazard ❑Flammable ❑Skin frritant ❑ Poison B ❑unknown ❑Return To Client ❑Disposal Sy Lab ❑Archive For Months longer than 1 month) <br /> Tum Around Time Required OC Requirements(Specify) <br /> ❑24 Hours ❑ 48 Hours ❑ r Days 1 a Days ❑ 21 Days ❑other <br /> i.Relinquished By Date Time 1.Received By Date Time <br /> �-rti_a ? a Jd 0-/r-o3 OIry <br /> 7RW1nquitjdBy Date Time 2.Received By Dat fd Time <br /> 3.ROnquished By Date Time 3,Received By Dat Time <br /> p Comments <br /> DISTRIBUTION. WH1TB.Returned M Client with Report; CANARY-Stays with the Sample; PINK-Field Copy <br />