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CHAIN OF CUSTODY RECORD <br />SGS Environmental Services Inc. <br />Locations Nationwide <br />• Ala3ka • Hawaii <br />• Louisiana • Maryland <br />• New Jersey • North Carolina <br />• West Virginia 0 6 719 9 <br />www.ussgs.com <br />' CLIENT: ~~ .. ~~ SGS Reference: ~ 3 <br />CONTACT: <br />PHONE NO:( e~r7~) <br />L ~ J 1 1 <br />~ O <br />C ~ <br />O <br />O <br /> <br />PROJECT: SITE/PWSID# : <br />N O <br />SAMPLE <br />TYPE Preservatlve <br />Used <br /> Anal <br />sis <br />REPORTS TO: ? E-MAIL: <br />S <br />'p FAX NO.:( ) C <br />N <br />T <br />COMP y <br />Required <br />O <br />3 <br />INVOICE TO: QUOTE # <br />2 P.O. NUMBER A <br />E GRAB <br />;~ <br /> <br />LAB NO. <br />SAMPLE IDENTIFICATION <br />.DATE <br />TIME <br />MATRIX <br />S j <br /> <br />REMARKS <br /> ~~zS CJ d o f S W G <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />5 <br /> <br />Collected/R " <br />` ui e <br />~ y:(1) <br />Date <br />~ <br />Time <br />~ q <br />Received By: <br />Shipping Carrier: ~ P <br />Ship~ting Ticket No: <br />Samples Received Cold? (Circl YES NO <br />Temperature JC:"~_T i ~• ) <br />Relinquishe ) Date Time Received By: Sped`al Deliverable Requ ments: Chain of Custody Seal: (Circle) :. <br />i <br />TACT BROKEN ABSENT <br />Relinquished y: (3) Date Time Received By: Requested Turnaround and Special Instructions: <br />Relinquished y: (4) Da <br />1°~3 Time Received By: <br />~ <br />} <br />J 200 W. Potter Dri+ro Anehorag <br />5500 Business Drive Wilmingt 99518 Tel: (907) 562-2343 Fax: (907) 5615301 O 1270 Gr nbrler Street Ch ~ <br />NC 28405 Tel: (910) 350-1903 Fax: (910) 350-1557 ton, 311 Tel: (304) 346.07 Fax: (304)346-0761 ~ ftn -Retained by Lab <br />Yeuow eturned with Report <br />Pin Retained by Sampler <br />