1998-03-23_REVISION - M1977348

• Permit No: M1977348
• IBM Index Class Name: Revision
• Doc Date: 3/23/1998
• Doc Name: EXHIBIT 6
• From: Holnam
• To: DMG
• Type & Sequence: TR3
• Media Type: D
• Archive: No

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CHAIN OF CUSTODY RECORD Lab r ry S e N s(A se
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ACZ Name to Appear on Repart and Invoice: cc: (Report) • (Invoice) to: (circle one or both)
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Laboratorlea, Inc.
30400 Do
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Projector P.O. M A NALY SES REQU ESTE D
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y REMARKS

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SAMPLE IDENTIFICATION
DATE
TIME Sam a
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IAaVU Options: SW (Surface wale) • GW (DfOUntl wafeq • WW (Wuuwafer) • OW (Drinknp wafer) • SL (Sludge) • SOIL • OIL • Other (Specify)
COM
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SAMPLE DISPOSAL OP170NS - P/eess complete section A, or choose one optlnn from ssct/ons B AND C.
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cold until (date)
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1) Local Disposal
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3) Relurn to Client
(CJ U Semple Is Hazardous
1) RCRA-Permitted Facility
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DELI HE IGNATUR E) DATE TIME RECEIVE BY: SI GNATURE) DATE TIME PAGE N
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