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Chain-of Custody Number <br /> SECQR Chain-of Custody Record ? 91v037 <br /> f s <br /> Field Office o me��� Additional documents are attached, and are a part of this Record <br /> Address ! z 3Y - 3 y sfr e e Job Name Z.- "" z� 2 C <br /> Location !Y 3 q U/eSf /v se rt ,''�P ✓e�� e— <br /> J!e 4 <br /> Project# 1.7/o — o a 2- o 1 Task# /_(,*l/o Analysis Request <br /> Project Manager <br /> Laboratory c- G 0 o °r° <br /> Turnaround Time a y o� <br /> °' <br /> O c7 m <br /> Sampler's Name � <br /> go pa o �m00 �d (2-= .000 2� 8o <br /> Sampler's Signature �, Ln E m Q1 m FQ o m a <br /> =r = = o a E a - E n N% ;g�, o=� -+ Comments/ <br /> U ao ao a acv ao QC\1 o od = m U z <br /> Sample ID Date Time Matrix s a z co cn�0 cit 10 4 9 1L 2 Instructions <br /> 1 - 5 -Iz S 35 X T i <br /> PI - o Le Ql <br /> ti <br /> 6-?3 -.s T50 X C1 14l <br /> e,- P3 -/o /0"00 X __P 0 ar19I <br /> P3 - IS l0'13 _] t <br /> Special Instructions/Comments Relinquished b Received by Sample Receipt <br /> Sign Sign Total no of containers <br /> Pant PnntChain of custody seals <br /> Brown /(,� ys(,-0�/O Company ��G 4 Company Recd in good condition/cold <br /> Time Date-7-/7,9V Time 0 Date 7-19-q(9 Conforms to record <br /> Relinquished by Received by <br /> Sign Sign Client <br /> Print Pant Client Contact reAt19dw0 <br /> Company Company <br /> Time Date Time Date Client Phone 7// 379-33 <br /> SECOR CUSTREC Rev 1195 <br /> Date 7112-/76 Page__L of <br />