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Chain of <br />Custody Record <br />STL-4124 (0907) <br />Client ~ 1 /1 <br />~, ,' i ~~, 1 yam. l_ ).- <br />Address <br />City, <br />i `i ~.- , ~~ .~- , <br />' Project Name and Location (State) <br />ContracUPurchase rder/Quote No. <br />' ..'y ..~ n ' 1~ <br />,.w <br />Project Manager <br />Telephone Number (Area Code)/Fax Number <br />r:' (C -' <br />~e Zip Code Site Contact Lab Contact <br />Carrier/Waybill Number <br />Sample I.D. No. and Description <br />(Containers for each sample maybe combined on one line) Date Time <br />fir, <br />Matrix Containers & <br />Preservatives <br />v g ~, _ <br />~n ~n ~ x ? _ <br />~ •• ~~ ~. J <br />• Y ..~ ~ <br />;, . <br />;.: <br />;,~.;. j <br />Severn Trent Laboratories, Inc. <br />Date Chain of Custod Number <br />t-_ 1~~872 <br />Lab Number <br />Page of <br />Analysis (Attach fist if <br />more space is needed) <br />Possible Hazard Identification Sample Disposal <br />^ Non-Hazard ^ Flammable ^ Skin Irritant ^ Poison B ^ Unknown ^ Return To Client ^,.Disposal By Lab ^ Archive For <br />Turn Around Time Required OC Requirements (Specify) <br />^ 24 Hours ^ 48 Hours ^ 7 Da s t._ <br />y ^ 14 Days ^ 21 Days ^ Other , ^, <br />1. Relinquished By s <br />Date Tme ~ 1. F~rscelved,Qy ~r <br />i ~'~ '~.. {ire ,.-1 ~017~~!!~~.. ../ r ., ~.'-. <br />2. Relinquished ey Date Time 2. Received By <br />3. Relinquished By I Oate I Ttme 3. Received By <br />Speciallnstructions/ ' <br />Conditions of Receipt <br />(A fee maybe assessed it samples are retained <br />Months longer than t month) <br />Date Time <br />Date Time <br />Date I Time <br />DISTRIBUTION: WHITE -Returned to Client with Repon; CANARY -Slays with the Sampte; PINK -Field Copy <br />