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rr� r r rr �r rr rr rr r� rr �r r r <br /> Chan o <br /> Custody Record Severn Trent Laboratories, Inc. <br /> SR-4124 (0700) Dae 'afn of Custody Number <br /> Client o .-�. , Pro ect M nager _ f <br /> )f\,p (7, 4TLllri'�p— o <br /> ��d Iress r T ph ne Number(Area Code)/Fax Number Lab Number <br /> I rl �` � e Page of <br /> �C r tate Zip Code Srte Contact ab Contact Analysts(Attach list if <br /> JfIIJ � `L � mores ace is needed <br /> } C( <br /> Pcge ocat ( t Carrrer/Waybdl Number A <br /> S ecra!Instructions/ <br /> GontiacUPurchase Order/Quote No Containers& <br /> Conditions of Receipt <br /> 3 f © 30'4 c. W Matrix Preservatives <br /> Sample 10 No and Description Date Time � � `s a 0 °z � ° <br /> (l-Vnldlnet,for each sample may be combined on one line) Q N �, ZI T x x z 111021 <br /> N C�J--F-- 477161 P. 3P X X I I X <br /> f„ I _ <br /> �v V = <br /> Po srble Hazard Identification Sample Dlsposaf <br /> (A lee may be assessed if samples are retained <br /> i rrHazard ❑ Flammable ❑ Skrn Irritant ❑ Prion 8 ❑ Unknown ❑ Return To Client 74osaf By Lab ❑Archive For Months longer than 3 months) <br /> Turn Around Trine Required QC Requirements(Specify) <br /> U 24 Hour ❑ 48 Hours ❑ 7 Days ❑ 14 Days ❑ 21 Days ❑ Ot r <br /> Hehnqurs 'd 8 Date Time 1 Received By Dale Time <br /> 2 Relrngrns ed 8y Vare Time 2 R erved By, 7 / Date Time <br /> ? !7l lr tushed B ate <br /> Time* 3 ed By Date` Time <br /> ['ornrnents <br /> DISTRIBUTION WHITE Stays with the Sample CANARY Returned to Client with Report PINK Field Copy <br />