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CHAIN OF CUSTODY RECOI*ND ANALYSIS REQUEST S klC)izl (� <br /> 5500 Boscell Common Fremont CA 94538 Tel 510 490-8571 Fax 510 490-8572 <br /> OWSIME Project Manager G e )01 Bill to <br /> E N V I R O N M E N T A L Client Name Company <br /> LABORATORIES, INC Address Address <br /> City, State ZIP � City, State ZIP <br /> Phone Phone <br /> Date /71 ?q Fax Fax <br /> Page 2 of <br /> Laboratory oi^5,4e l:nV Project Name G /Cr {� f a P 0 Noc/-73W2/VA S �i <br /> Lab Number 2 F of 6 Project Number 3no q AI (� C] <br /> Analy Is Requested <br />� � t <br /> co <br /> V ¢ a 0 a <br /> a <br /> E F m u Q W Z z <br /> Sample Identification Date Sampled Time Sampled Matrix E m a a 1_x•1 Z Remarks <br /> ARAZ-1 / �!U /S30 H 2F016- 479 b4'- <br /> V Y Z ( S 5S_ I <br /> 4 Al /6/0I�V616 - tl Y 2- <br /> �Cn-2 - S9 S 9 /l ��` 12 Yr I Y2 <br /> Initials Printed Name Signature Date Total Containers <br /> MY N 'CINC ek jurovsL `► wa r tart Time Received Intact <br /> r3r 1 q,vf'r Stop Time Received Cold A <br /> Hours Custody Seals <br /> Client Sign-off <br /> White Copy -Admin/Lab Yellow- Mobile Lab Pink- Client <br />