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The fe~Cr~ft Group <br />An EnvlronmanW Servlcav Company <br />1341 Cannon Street • I-oulsville, Colorado 80027 <br />303-661-9324 • FAX 303-661-9325 <br />Client: ~ Contact: <br />Collected by: <br />Sample <br />Sample Identification Date Type <br />C......J...i' Tim.. <br />Chain of Custody Record <br />(enclose with each shipping container) <br />Acute <br />o c° `ro`~ <br />p c y <br />V ~ v <br />~~ .~ I <br />Address: <br />iC'o t~ <br />Chronic <br />3 w <br />o c° m <br />e <br />V ~ U <br />LS .V I <br />Purchase Order Number <br />Project Numberllab use only) <br />`~~ i~~ <br />\These fields may be used <br />for field test results <br />r <br />~~~ <br />Total Total <br />~ ~Yll}C ~rtlll IYIIP <br />1 ~ .d <br />2 <br />3 <br />4 <br />5 <br />6 <br />7 <br />8 <br />9 <br />10 <br />Comments and special testing instructions: <br />Relinquished by, <br />Relinquished by: <br />Next recipient: _ <br />Representing: U~\ CG To Whom: ~~ Date/"fime~lJ~~ <br />Representing: To Whom: Date/Time: a <br />Relinquished by: Recd by: ~'~- Date/Time: C~ii ii~u 5 <br />-ru J <br />