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[{"$nulls":7},"CHAIN OF CUSTODY RECORD",{"$nulls":30},"Page __ of __"]
["Logo",{"$nulls":6},"M. J. Reider Associates, Inc.",{"$nulls":10},"ALL SAMPLES MUST BE DELIVERED ON ICE"]
[{"$nulls":7},"107 Angelica Street, Reading PA 19611",{"$nulls":27},"Turnaround Time"]
[{"$nulls":7},"Phone: 610-374-5129   Fax: 610-374-7234",{"$nulls":11},"*Sampling instructions and safety info can be found at www.mjreider.com. Please see form instructions and Terms and Conditions on back side of form.",{"$nulls":16},"Standard"]
[{"$nulls":7},"www.mjreider.com",{"$nulls":28},"RUSH (*additional fees may apply)"]
[{"$nulls":35},"Need RUSH Results By:  ____/____/____"]
["Client:",{"$nulls":14},"Address:"]
["Contact:",{"$nulls":14},"Email:                                                                                                                                                                                                              ",{"$nulls":19},"Phone:    "]
[{"$nulls":9},"Matrix Codes",{"$nulls":4},"Container Codes",{"$nulls":5},"Preservative Codes",{"$nulls":4},"Notes:"]
["_________________  Composite Info",{"$nulls":8}," WW = Waste Water",{"$nulls":4},"Size",null,null,"Type",null,null,"N = HNO3        T= Na2S2O3"]
["Start ____/____/______ @ ______  ",{"$nulls":8}," DW = Drinking Water",{"$nulls":4},"L = Liter",null,null," P = Plastic",null,null,"S = H2SO4          E = EDTA"]
["Stop ____/____/______ @ ______",{"$nulls":8}," GW = Ground Water",{"$nulls":4},"500 = 500mL",null,null," G = Glass",null,null,"C = HCL       Z = Zinc Acetate"]
["_________________  Composite Info",{"$nulls":8}," ST = Storm Water",{"$nulls":4},"250 = 250mL",null,null," V = VOA Vial",null,null,"P = H3PO4         L = NH4CL"]
["Start ____/____/______ @ ______  ",{"$nulls":8}," S = Soil/Solid",{"$nulls":4},"120 = 120mL",null,null," S = Sterile",null,null,"H = NaOH        A = Asc. Acid",{"$nulls":16},"PO#"]
["Stop ____/____/______ @ ______",{"$nulls":8}," O = Other",{"$nulls":4},"40 = 40mL",null,null," O = Other",null,null,"R = NaAsO2       O = Other"]
["  Sample Collected By: (required)",{"$nulls":18},"Matrix","Grab","Composite","Bottle Count",{"$nulls":7},"            Container Size (use codes listed above)"]
[{"$nulls":30},"            Container Type (use codes listed above)"]
["LAB ID      (Lab use only)",null,null,"Sample Description (Location Name)",{"$nulls":11},"Date",null,"Time",{"$nulls":11}," ","            Preservative (use codes listed above)"]
[{"$nulls":24}," ",null," ",{"$nulls":3},"Analyses Requested"]
[{"$nulls":24}," ",null," "]
[{"$nulls":24}," ",null," "]
[{"$nulls":24}," ",null," "]
[{"$nulls":24}," ",null," "]
[]
[]
[]
[]
[]
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["Comments: (Lab use only)"]
["Relinquished By:",{"$nulls":14},"Date:",null,"Time:",null,"Received By:",{"$nulls":11},"Date:",{"$nulls":3},"Time:",null,"Sample Receipt"]
[{"$nulls":37},"(Lab use only)"]
["Relinquished By:",{"$nulls":14},"Date:",null,"Time:",null,"Received By:",{"$nulls":11},"Date:",{"$nulls":3},"Time:",null,"Sample Temp (oC):  ________"]
[{"$nulls":37},"Samples on ice?    Y     N     NA"]
["Relinquished By:",{"$nulls":14},"Date:",null,"Time:",null,"Received @ MJRA By:",{"$nulls":11},"Date:",{"$nulls":3},"Time:",null,"Approved By:  ________"]
[{"$nulls":37},"Entered By:  ________"]
["The Client, by signing (or having the client's agent sign) this Chain of Custody Form agrees to MJRA's Terms and Conditions and to pay for the above requested services including any and all attorney fees if collection becomes necessary."]

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