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fjc� �J/DZSANALYSIS REQUEST/C" CUSTODY RECORD <br /> BSK Log Number_ A�j Analysis requiredProject O�Client Nafne <br /> " <br /> !ab use only t <br /> /1 C Phone 0 u 7 In this � <br /> VJ �� �l a i�/ m© section <br /> Address <br /> / S <br /> City Stale,Zip Report attention C �� <br /> �� <br /> Stock�� ("It �Z� ~� ��`�� ) <br /> Sampled by Number !ab Sample <br /> \ ( — <br /> gate Time TYPE �t V� of Sample 0�� �`$� �jV�`t �qC <br /> sampled sampled ntainers number (See key rayl Remarks y <br /> below) Sample desorption below) <br /> IMPORTANT NOTICE No samples will be analyzed without an authorized signature In this section <br /> I am hereby requesting BSK s Normal Cham-0f Custody Procedures for the above samples I understand that I am hereby requesting BSK s Formal Chain-ol-Custody Procedures for the above samples I understand that <br /> these procedures are generally consistent with(hose outlined In the US EPA 5W 846 and That!here IS no these <br /> procedures <br /> generally consistent <br /> nilin US <br /> nlract aratory �rState- <br /> ment <br /> ofSeclonIF and that there is acharge of$$5000 per order or$500bottlewheveris <br /> extra charge for this services greater <br /> By <br /> By <br /> Authorized Signature Authorized Signature <br /> Signature Print Name Company Date Time <br /> Relinquished by ` �s7�,f� G t t C lomat _ `�/ V� 6/' <br /> Recei by ' sem <br /> Re1i ed by— <br /> Received r <br /> N� Ci �f�/ ,7� PLt��/�S.�SvTD,✓ /• °�'U` <br /> Relinquished K,►� <br /> Received by f7 <br /> /O.e <br /> KEY Type AQ- u sus Sludge SO-Soil PE-Petroleum OT-Other <br /> Seats P-Prose Ab B Broken <br /> Cr'eOg- <br /> C`i5lefnical Laboratories 7 DISTRIBllTIO�I_T CANARY LABORATORY PINK ORIGINATOR r <br /> _ I Note �� i/ Il/ell <br /> P' A s Samples are dlsdazd� 4 days after results are reported unless other arrangements are de <br /> r ,4�5 a, a i arnia 937(}6' �} Hazardous samples will be returned to client or disposed of at client expense J <br /> /l �nTete�one{Z ,Fax' . y I ) ` I/X�� 1 ' - ��� / - 1 <br /> r1V - - �` <br />