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I I 1 1 1 1 I I I I 1 I I I I I 1 I 1 <br /> Por habooa0ry use Only <br /> ADVANCED TECHNOLOGY CHAIN OF CUSTODY RECORD RwlyWit. <br /> mmman Y u <br /> L A B O R A T O R I E S Page-of ❑onto ❑At. J,CMUED ❑ s.AofsAMp1ESSMAWHOOr E"❑ <br /> ❑moan Ri 2111 JACEIVMI al. ❑ a s.paf5[NYED ❑ <br /> 3275 Walnut Ave.,Signal Hill,CA 90755 0sS0 aroxwxmlmArr .a ❑17TEMe dad C: <br /> Tel:(562)989-4045 a Fax:(562)989-4040 Instruction: Complete all shaded areas. D Omd' 39CONTU ❑ <br /> rrt <br /> Company: Geocon Consultants, Inc. ddress: 3160 Gold Valley Drive,Suite 800 el: (916)852-9118 <br /> City: Rancho Cordova. tate:CAPip: 95742 Fax: (916)852-9132 <br /> w SEND REPORT 70: i <br /> I SEND INVOICE TO: 11same as SEND REPORT TO <br /> Attn: �— ttn: Emai <br /> N Company: Geocon Consultants,Inc, Company: .. <br /> uAddress:�,�,//Q <br /> ity: . /'�'PE�'L r7 / a(��i tateS/A ip� Z CItY. tate: jp; <br /> Project Name: `, ,/ ,/ Quote No: SP i, l)instructions Comments: <br /> �j—�� 4es/ � O Encirtle or Write Requested Analysis Encircle Sample Macri Container a /Q� <br /> Project No.:SCJ8 V i ,_ g ❑Routine <br /> as-o�3 G6 �f� <br /> PO#: 3 _ ad i # altrans <br /> ampler: �f� /�% CGS(=� �lN f t� o 2 o 5 or WRCB <br /> b ❑Leaal <br /> do u AT 3 a r <br /> w i <br /> ad <br /> ro to po A s. <br /> Sample Description u v do 3 0 <br /> W Y <br /> w Lab No. —, n — c <br /> Y <br /> Uri <br /> w — Sample ID/Location Date Time w w mdoo <br /> 0 3 a <br /> 1 E(OJR-7�7 / /- wZS � % y <br /> e'r2 -L !��- YS <br /> eu g <br /> eu <br /> 0 4 <br /> c <br /> C. <br /> 5 a <br /> 6 <br /> 7 <br /> 8 <br /> 9 <br /> 30 <br /> 1.auuneu Nwn:BMAM Io500pM M-f;YlurtlNBWOM to Ii00pM. S.JUYonrn¢TATb IO 35Ws0eedy,i.TAT=S1mne1larµarwprcr(oryuprmrntoMresrirepuNesanaWlabnal <br /> i.Samples SubmlXetlARER 3:W pMert eauitleretl rc¢Nea lM1alW VMn6 Rminess Gy al B9DAM. .Whome-ail As the authorized agent of the company above,I hereby <br /> J.TMItllowleg onnamurM Xme mMlMm appy, 6.upuN ana wW snryleyaM Namtyreeo-as w5l be W dad IIaSaleMrarys lrm repel Gl¢ <br /> EW.WNI e0lbedipusetlal lDalma.ram wm mpert aaan. purchase laboratoryservices from ATL as shown above and <br /> TAT=0:31p%3urW rge SAMf DUSWE55 DAY IhreWrNtry 9:W AM <br /> p.EaWren4 reeema reaNnee ra,Raw slyxi. hereby guarantee payment as quoted. <br /> TAi=1:10]%surrloge NEATBULNFSSDAY CDXS:D]pM) <br /> TAT-$:'A%SAehWAe3ND1HU1W.S 0dW(O.d S:WpMl a.SW$c dntl Repan Ee=alapplieiwM1en elegy lirryue4eaerwMn Mra a'opyb rteuiWtlor n6nnm[<a: yg P y <br /> W tAT•3:3D%$'n %eCNAME3ROBULNESJDAY(C 500pM1 Upala&adla.mplei:CampNmanlaryarwage lwbM hirtlaSlaaleMar aaKakerrroon tore $3.W/sample/nwlMrtaher. <br /> Dt ~ TAT.a:,O%Sunch me4TMeUSNES$OAYICOa$:Mil AY and ye Samplei:Compllm4Xary Yony rm aeon 110)calendar di after mart dare-$1.W/seal ne.'ErNeaded, <br /> TAi•s.XOSURCNMOF SiM1 W51NFSt MY1COR500 sloop.) Denteratlon W hard copy Real$17.50 Nor MW;Reopen rendennun or nifwmaXiry:$$0.ropx repa6 <br /> 4.WttWE,haaay.on.no 1o.Wallpal add <br /> swill old to <br /> a 9i feePerPer nnpwie Parr duenal. Submitter Print Name <br /> _ Si re <br /> nand ted Name I Date: �/ Tlmey.•a 'J ¢cele¢ ,signator¢ dg jl Name �_ Tim <br /> O Re Inqui d b>larffhae and printed Name) ,Date: Time: Received by:(Signature and Printed Name) Date Time: <br /> R Inquishe by:ISignmureantl prole,Name) Date: Time: Received thl(Slgnature and prinmd Name) Date: Time: <br /> u <br />