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CHAIN OF CUSTODY RECORD <br />SGS Environmental Services Inc. <br />Locations Nationwide <br />• Alaska • Hawaii <br />• Louisiana • Maryland <br />• New Jersey `• North Carolina <br />• West Virgihia O ^ ~ 0 <br />:wwwuasgs.com b <br />CLIENT: w (, SG <br />S <br />en <br />ce: <br />Re~fer <br />' <br /> <br />CONTACT ~~ PHONE NO:(ai 1~) 8 ~~ ~'f ~Ob ~ <br />7 <br />(` <br />' <br />' <br />( <br />17 t ~ <br />PROJECT: ~ SITE/PWSID# : N G SAMPLE <br />TYPE Preservatives <br />used <br /> Anal <br />st <br />REPORTS TO: E-MAIL: <br /> <br />!' FAX NO.:( ) O <br />N <br />T G <br />COMP y <br />Required <br />O <br />3 <br />lNVO1CE TO: QUOTE # <br />P.O. NUMBER <br />2 A <br />N <br />E GRAS <br /> <br />LAB NO. <br />SAMPLE IDENTIFICATION <br />DATE <br />TIME <br />MATRIX R <br />g <br /> <br />REMARKS <br />2 ~V (O !b O S W 2 (~ <br />i <br /> <br /> <br /> <br /> 1 <br /> <br /> <br /> <br /> <br />5 <br />4 3 <br />r <br /> <br />~ <br />Colle Iln hed By:(1) ate <br />r2t~ a Received By: i Shipping Carrier: V fl~ <br />Shipping Ticket No: 1` Samples Receiv old? Cird YES <br />; NO <br />Temperature jC: i <br />e inquished By: (2) Date Time Received By: Special Deliverable Requirement Chain of Custody Seal: (Circle) <br />" TAC BROKEN ABSENT <br />Relinquished By: (3) Date Time Received By: Requested Turnaround Time and ecial Instructions: <br />i <br />Relinquished By: {4) Dat <br />~ Time <br />lOC~ Re eived By: <br />~" <br />~ <br />u wu w. rover unva cnorayr., pR 98518 7eL (9l>s61•z34-s Fax: (907) 561-5301 O 1270 Greenbrier Siroet Charbaton, WV 25911 Tel: (304)346-0725 Fax: (304 346-0761 ~ White -Retained by Lab <br />O 550D Business Drive "Wilmington, NC 2t14D5 Tel: (9 ) 350.1903 Fax: (910) 350-1557 i Yo11ow - Returned with Report <br />Pink -Retained by Sampler <br />