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M <br /> \ „ gdes='49tg�aaDATE G OFalusoy � PA <br /> p2'- <br /> PROJECT <br /> MANAGER f3 ! E Recommended Quantity and Preservative (Provide triple volume on QC Samples) <br /> COMPANY <br /> ADDRESS <br /> O Qo U U U x 4 Z o a 4 <br /> N N N O O O O D O O O <br /> BILL TO :5) N ? h o <br /> COMPANY o 0 <br /> ADDRESS, <br /> 'Q NQ D ro o b h <br /> o v <br /> rz c <br /> � Q <br /> SAMPLERS (Signature) PHONE NUMBER U <br /> C m <br /> U w o o c� m m U <br /> SAMPLE o 4S 2 z `° o c - . w `m <br /> SAMPLE 1D DATE TIME MATRIJI( LAB ID m p C oma` a, U o o U o <br /> O C7 4] U � U x <br /> Z34-oE� s17 146$ <br /> 7 r 3 <br /> k <br /> ------------ <br /> ------------------------ <br /> 'x ------------------------ <br /> PROJECT INFORMATION _ ' �. i_�''SAMPLE RECEIPT- RELINQUISHED BY 1 RELINQUISHED BY 2 RELINQUISHED BY 3 <br /> PROJECT NUMBER ;'TOTAL NUMBER OF CONTAINERS,• Signature Time Signature Time Signature Time <br /> PROJECT NAME JbHAINOFCUSTODYSEALS YIN/NA Printed Name Date Printed Name Date Printed Name Date <br /> PURCHASE ORDER NUMBER SEALS INTACT? YININA <br /> VIA RECEIVED GOOD CONDYCOLD Company Company Company <br /> TAT 024HR ❑48HRS ❑72HRS❑1WK E72WK LAB NUMBER RECEIVED BY 1 RECEIVED BY 2 RECEIVED BY (LAB) 3 <br /> SAMPLE DISPOSAL INSTRUCTIONS 'r� <br /> Sr -e Time Signature Time Signature Time <br /> ❑ ATI Disposal @ $5 00 each ❑ Return ❑ Pickup 6�36 <br /> CommentsJ Pnnt d N e�S� Date Printed Name Date Printed Name Date L/yj <br /> Company Company Analytical Technologres,Inc <br /> DISTRIBUTION White Canary ANALYTICAL TECHNOLOGIES INC•Prnk ORIGINATOR <br />