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CHAIN OF CUSTODY RECORD <br />'' ~',``. <br />; ~~~,~ Specialty Analytical <br />=~ ~+~ ~ ~ 19761 S.W. 95th Place <br />:~~ ~'~-- Tualatin, OR 970G2 <br />~_~ ~~~ (503) 612-9007 - Phone <br />"_ (503) 612-8572 - Fax <br />,i <br />~ ~ .~ <br />. `~ <br />Coliected By: %~ ~~ ` ' ~ <br />Signature ~.-,"'~; ~~sc1~_''~ <br />Y, Printed 1i_: (-, 4•~..,' ,.~ :~ . ~, ~~.<: 1 <br />Contact Person/Project Manager ~ ° ~~ '• ~-. }"~ ~~~- ~- ~ ~ • ' F• <br />i <br />Page_(_of_ <br />Company ~~ ~J':-~,L~j L_;r-;'i `.-asC~f:..:t_!_'~:.~,.,'~, r~r;• ? - <br />Address /~'".: ` ,r.i ; : ~u Lr:' "~"f. ,~, ~!, •i ! ~~ ~ ~ -'`~ ` - - <br />t'G;r ~:..~ti;~il :..y,2 ;...~.1^ f -- <br />, . _. ... : <br />, :'~ <br />Phonei `r?~~~ '~>1-l;c+i'; Fax .b?' - " .''{~'~ <br />Project Na ~I~~:~;: ;~^~~1~~~": ; ~~I'.~ ~~ Project Name C; :~.i ~~~i::~~~..'. :•,,:'r~`~- <br />4• <br />invoice To c`~~~ i= ~• P.O. No. <br /> For Laboratory Use <br />SignatuFe <br /> Lab Job No. <br />Printed <br /> y Shipped Via <br /> <br />Turn Around Time ~ <br />S <br />. Air Bill No. <br /> ~ <br />^ Normai c ^ ; <br />^p Rush ~ '-t '1r~ , <br />~j <br />'-~ <br />Temperature On Receipt °C <br />Specify o ~~ \- Specialty Analytical Conlainers~ Y/ N <br />Rush Analyses Must Be Scheduled With The Lab In Advance ~ <br />Z '~ <br />`~ +~" <br />~~~ Specialty Analytical Trip Blanks? Y/ N <br /> ~-~ a <br /> <br />Date <br />Time <br />Sample I.D. <br />Matrix -~3 <br />Comments <br />Lab I.G <br />~J7(~~`J~ r.71~,~~ r i=,=~,/`~:.%•;r (~~` L( ~` ,/ <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> ;.,~•14~~ '=i~t~~;".nc~ ~~~t <br /> r~ 1; - "Z,';--; ~ <br /> ' ~ . . <br />~,~!i ~~ i~~' i~a'~i~~ <br />Relinquished By:...~~• - ~ ~•`~ Date <br />.; Time Received B <br />y: Relinquished By: Date Time <br />Company: f.. (,..J r-~, ~._._ ~ <br />~, <br />'~"!~; '1 + /..; (~ Company: Company: <br />Unless Reclaimed, Samples Wilt Be Disposed of 60 Days Afler Receipt. Received For Lab By: Date Time <br />Copies: White-Original Yellow-Project File Pink-Customer Copy <br />-- <br />~ ~ ~ <br />