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Chain of
Custody Record
QUA 4124 07 97
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L't LO 10"banterra
Client
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'lfXn^'l n Project Manager Oaf I ^—
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Address Telephone Number (Area Code) Fax Number Lab Number
City State Zip Code Site Contact Lab Contact
Project Name
Contract'Purchase Order/Quote Noo -
Sample I.D. No and Description
(Containers for each sample may be combined i on one line)
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VI
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— / n / CarrierlWaybill Number
Date Time
Matrix
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Containers 8
Preservatives
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N i
Analysis
more s ce
(Attach list if
is needed
Chain of Custody Numb P,t
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Page of
Special Instructions/
Conditions of Receipt
P >a,
(A lee may beetl if samples are retained
El No,, Hazard q Flammable q Sbn Irnlan( L1 Poison B Vonknowi, Return To Client El Disposal By Lab q Archive For Months longer than 3 months)
Turn Around Time Required OC Requirements (Specilyr
q 24 tVrirs q 48 Hours q / Days q 14 Days y21 Days q Other
in uished Date Tema 1. Re ed By s Date Time
`-- 2. Relinquished By Dale Time 2 Received By Date Time
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R ^.^n uished q BY ^ Dale f Time — 3. Received BY
I Dale I Time
GominenR
DISTRIBUTION: WHITE - Slays with the Switch,, CANARY - Returned 10 Client with Report PINK - Field Copy
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