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Chain-of Custody Number <br /> SECQR Cham-of Custody Record <br /> UIkField Office AC F}^wt. ru I <br /> Additional documents are attached, and are a part of this Record <br /> S�r`� Job Name [o11oc 0 <br /> Address y� . .._..._._....... <br /> Location k �il) CA- <br /> T <br /> � II <br /> Project # _Task# 7DO7_ II Xnalysis Request <br /> Project Manager Jbl 8 D&VCr I I <br /> Laboratory 0 o W <br /> Turnaround Time. � (Ltr a a to us ro m� <br /> �U U <br /> Sampler's Name - �! !'T �woo D �o si o 2N o M o 191;2 <br /> _ m <br /> Sampler's SI nature 3� i°.8 IDT N c$ `� ' y a E <br /> 9 G _t2 LO x a A03 �i E�, n 3 N o' a Comments/ <br /> U a o a a a o ow �^ a�N d ov m U Z <br /> - <br /> Sample ID Date Time Matrix = i-m �co ¢( � x cn(n a co �-r, d h Instructions <br /> t� av N o <br /> J � <br /> l l <br /> 11 !i <br /> 11 II <br /> l II II I <br /> if II � <br /> l <br /> II II I <br /> Special Instructions/Comments Relinquished by _SE's Received by Sample Receipt I <br /> Sign Ab !! Sign Total no of containers <br /> Print 6AWr CIiT _ . . _!! Print 'I�2 �2�4 N Chain of custody seals <br /> t Company 6EC0f` Company � Rec'd in good condition/cold <br /> Time _HS,9_ Date Time 9 3 0 Date i e, Conforms to record <br /> Relinquished by Received by <br /> Sign !! SigClient <br /> n <br /> Print !! Print Client Contact <br /> Company ! Company <br /> Time Date Time Date Client Phone 60,q!_71:9333 <br /> if II i i <br /> SECDA CUSTREC Rev V95 ' <br /> Date Page_J_of <br /> . <br />