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Chain of Custody Record 1 Date: <br /> CTIAnalytical ChemTech � � Page: / of <br /> International, Inc. Billing Information: <br /> 4011 Power Inn Rd. Company Name: '- Company Name: � <br /> Sacramento, CA 95826 Address: Address: t y ,FD Y -7 <br /> City, State, Zip �; % City, State, Zip: �►i �/ //1 rY�` <br /> Phone: (916) 455-2284 Telephone <br /> FAX: (916) 455-0191 Telephone <br /> FAX i' „ ; , ,;; ", / FAX: .� <br /> Project Name: '•"�';�` �' •,: x':- Report Attn: Contact: <br /> Project #: ;.. <br /> Contact: 1.-- r T <br /> P.O. #: <br /> Sample Control Check y <br /> Sample Date Time Tests # of Sampling Remarks (include Number <br /> ones <br /> Location/ <br /> Identification Sampled Sampled Required Jars Method type & appearance) Lab Use <br /> Position <br /> Only F' %P <br /> Z <br /> Total Number of Containers: Sampler's Signature: % F:-Finned <br /> Relinquished by: Company Relinquished by: Company Relinquished by: Company <br /> Received by: Company Received by: Company Received bynVbb.- Company -�oo. <br /> Data/Tune - Temp (`C) Date /Time Temp (`C) Date /Time, Tamp(*CI1720 <br /> r sY <br /> Distribution: White, Canary - Laboratory Pink - Originator NOTE: Samples are discarded 30 days after results are reported unless other arrangements <br />