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Chain of <br /> Custody Record Severn Trent Laboratories, Inc. <br /> STI- 1124 (0760) l Date ! Chain af�u'VO <br /> Clientdy Ntlfrr er <br /> Protect Manager ( F <br /> ' l ` <br /> AddressTelephone Number(Area Codp)lFax Number Lab Number <br /> `41 / �` i Page of <br /> i <br /> City State Z+p Code _ ] Site Contact Lab Contact Analysts(Attach list if <br /> t_ <br /> mores ace is needed <br /> Project Name and Location(State) ( r F f 7` r Carnet/Waybill Number <br /> ! l Special lnstructlons/ <br /> Conditions of Receipt <br /> Contra,Upurchase Order/Quote No Containers 8 <br /> 7 ' Matrix Preservatives <br /> Sarnpie 1 D No and Description Date Timea — c ° z o N o <br /> rJ <br /> (Guntaiiu,ra for each sample maybe combined on one fine) t Q <br /> tf � <br /> 4 � <br /> NK ti <br /> Possible Hazard Identification Sample Disposal <br /> � (A lee maybe assessed if samples are retained <br /> ❑ Non Hazard ❑ Flammable ❑ Skin Irritant ❑ t Orson B ❑ Unknown ❑ Return To Client ❑ Disposal By Lab ❑Archive For Months longer than 3 months) <br /> 1 urn Around Time Required ' i/ QC Requirements(Specify) <br /> ❑ 24 Hours ❑ 48 Hours ❑ 7 Days ❑ 14 Days ❑ 21 Days ❑ Other <br /> 1 Relinquished By Dale Trme 1 Received By Date Time <br /> `l <br /> 2 Rehnqurshed By Date Time 2 Received By Date Time <br /> 3 Relinquished By Date Time 3 Received By Date Time <br /> i <br /> Cornments <br /> DISTRIBUTION WHITE Stays with the Sample CANARY Returned to Client with Report PINK Fie)d Copy <br />