Laserfiche WebLink
Chain of <br />Custody Record <br />SrL•at2a (osou <br /> <br />®~ `' <br />Severn Trent Laboratories, Inc. °' <br />~1°"' Project Manager Date Chain of Custody Number <br />Address Telephone Number (Area Code)/Fax Number Lab Number a <br />/ ~ ~ Page of <br />City State Zip Code Site Contact Lab Contact Analysis (Attach list if <br />`. ~1~~ ,, , ~~~ (C:~ '°' -~ ~ 5 .~ ,; h ~..-{ ~, M< mores ace is needed <br />Project Name and Location (State) Carrier/Waybill Number <br />~! ~ `~~~ `~ ~~ ' ~ `' _~ ~ ~ Special Instructions/ <br />ContracUPurchase Order/Quote No. Matrix Containers & Conditions of Receipt <br />Preservatives <br />Sample 1. D. No. and Description ~ --- v o ~ _ ~ _ <br />Date Time a~ a ~ o o a o <br />(Containers for each sample maybe combined on one line) <br />d g cn ~, j 2 = = 2 N 2 <br /> II <br /> <br /> <br /> <br /> <br /> <br /> i <br /> <br /> <br /> <br /> <br />Onecih/o 4J~»r.11,-I....~:Fnol:nn __._.. <br />(A fee may be assessed i/samples are retained <br />^ Non-Hazard ^ Flammable ~ Skin Irritant ^ Poison B ^ Unknown ^ Return To Client ~ Disposal By Lab ^ Archive For Months longer than 1 month) <br />Turn Around Time Required O Regwremenls (Specify) <br />^ 24 Hours ^ 48 Hours ^ 7 Days ^ 14 Days ^ 21 Days 4 Other l~. ! <br /> <br />r <br />1. Re'li(nquished By /~ Date o ~ ^i Oe~ p 1. Received By %~ Date / Time t <br />2. Relinquished By Date Time 2. Received By ~ dr - D to/~ ~~ Tirne <br />3. Relinquished By Date Time 3. Received B <br />y I Date I Time - <br />ow rrrretu t tUN: wHII t - rreru(neo to went with Report; CANARY -Stays with the Sample; PINK • Field Copy <br />