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t ° A � ANALYSIS RE ST AND Reference Document N 0230 <br /> 20 <br /> �ig,t�oup a � <br /> `�C OF CUSTODY RECORD* Page 1 of <br /> Project Name/No 1 Samples Shipment Date 'g��Z.. Bill to 5 `79 1 ��3 �p3f'�CICY1[`)rt] <br /> Sample Team Members 2 Lata Destination 8_ <br /> Profit Center No 3 � ��023_� t Lab Contact o <br /> Project Manager4 Project Contact/Phone 12 � ag� -,,�L qc) Report to <br /> 10 m <br /> Purchase Order No 6 Carrier/Waybill No 13 <br /> Required Report Date 1 3 <br /> CD <br /> m <br /> Sample 14 Sample 15 Date/Time Container1 mPle� Pre• 19 Requested Testing 20 CondRion on 21 Disposal 22 <br /> Nlumber Descrt on/T a Collect ed T Volume servative ra Recosrd No <br /> I nV711r—, <br /> Mw-z- '4kk'v"5- qML J46k <br /> t --1 nn L 3 LI VD <br /> -3 JIM <br /> Kw 15:5 qOWL <br /> 9 rV�-, m <br /> Cr <br /> x <br /> Special Instructions 23 <br /> Possible Ha and Identification 24 Sample Disposal 25 <br /> Non haze flammable J Skin Irritant J Polson B J Unknown J Return to Client J Disposal by La Archive (Mos ) m <br /> TurnqrotAhd Time Oequired 26 QC Level 27 m <br /> Norma Rush CJ I C„J II J III r Project Specific (s ec ) s <br /> 1 Relinquished by Date 16 1 Received by 28 Date <br /> (Signature/Affihauon) Time f lsignawre/Aftibabon3 <br /> Time r o <br /> 2 Relinquished by Date 2 Received by Date v Q�- W <br /> (signswre/Affiliation) Time ls�gnawre/Affiliation) � Time <br /> --2, 1 <br /> 3 Relinquished by Date 3 Received by Date <br /> (Signature/Affiliation) Time Vw km lel r /Affiliation) <br /> Time <br /> Comments 29 _ M <br /> w�0 UPON n" iIATE <br />