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M M M M M � MM M mi+�#01 <br /> BSK Log Number <br /> ANALYSIS REQUEST/CHAS CUSTODY RECORD 51M <br /> Client Name Q /U �� Protect QZ POO � Analysis required <br /> /''T ��Cl �! �J�GS ' hij � ��' Lab Use Only <br /> phoneIn this <br /> Adder ss <br /> Zv,5j(J section <br /> City Stae +p Report attenhon <br /> CA <br /> Sampled by /, //.�� VNber Lab Sample <br /> Date Time Type �' �`'"h '/� u p Seals Q ryry� m <br /> �e ke Same See k /C y <br /> S, <br /> sampled Sample de rrrptlon ners number ( r Remarks <br /> below) below) <br /> Zai <br /> 41 <br /> :/::EL <br /> f - /3 rte! - - Z Ze <br /> 9,� s V u/-I 4 �� �� 69 <br /> /o,ro VEff I <br /> /Z 11 56 V45Y 1001 <br /> VFW-I *7 <br /> /3;53r Agji <br /> IMPORTANT NOTICE No samples will be analyzed without an authorized signature In this section <br /> I am hereby requesting BSK s Normal Chain-0f Custody Procedures for th above samples I understand that I am hereby requesting BSK s Forma!Chaln-of-Custody Procedures tot the above samples I understand that <br /> !hese procedures are generally consrsienl with those outlined I U ASW 846 and that there is no man ofrWork rSed+on F,es are n ndlthat!here is atchathose <br /> rge of$5000 per,workEPA <br /> orderntract or$500baratory bott a Pw�rheveram tise <br /> extra charge for this service greater <br /> By <br /> r zed nature Authorized Signature <br /> Slgnatu Print Name Company Dale Time <br /> Rehnq ished b A� <br /> Relinquished by y�azo - /yl�� ir�� +'C-i✓k5 470 TZ) t"' 3 <br /> Received by <br /> Relinquished by <br /> Received by !"'`Y <br /> r � V -Ui 5 KEY Type AO- ueous SL-Sludge SO-Sod PE-Petroleum Ofr--Other <br /> Seals P-Present A-Absent B-Broken / I <br /> ` & ASsot feS Chemical Laboratories DISTRIBUTION WHITE,CANARY LABORATORY PINK ORIGINATOR <br /> Note <br /> Samples are discarded 14 days after results are reported unless other arrangements are made <br /> 1414 Stanislaus Street Fresno, California 93706 Hazardous samples will be returned to client or disposed of at client expense <br /> Tefep on;M 4 5 8310 •.F D9) 4 427 <br />