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CHAIN OF CUSTODY RECOF&ND ANALYSIS REQUEST <br /> 5500 6oscell Common Fremont, CA 94538 el 510 490-8571 Fax 510 490-8572 <br /> ONS'TE Protect Manager Sill to A <br /> E N V I R O N M E N T A L Client Name U P-S r e Company <br /> LABORATORIES, INC Address Address _ <br /> City, State ZIP City, State ZIP - <br /> Phone /< 2 3 4'- LY fb Phone <br /> Date9 Fax 2- / Fax <br /> Page of <br /> Laboratory On5I Protect Name C 45k run r cv�rC' P 0 Na �� 3 �y �j ��rll 2 /C t <br /> Lab Number 1 Q! Protect Number 5 3 UU (5?tiA -c3 <br /> Analysis Requested <br /> Ln <br /> m <br /> atr <br /> w 2 2 v <br /> Sample identification Date Sampled Time Sampled Matrix ) E � J m a a z Remarks <br /> MW-fa - Y� < < 1 0 S ztralc- t.� X -5 <br /> b - 5 5 1 Sn 1,�1 P 1 k <br /> - 1y 3 <br /> q � klo w <br /> V -� - la 3 <br /> VLA)-a - y v - is ar. <br /> Initials Printed Name Signature Date } S Total Containers <br /> M 7 M;C�,c,,e� %�r��s �y __� Start Time Received Intact <br /> Ur �4 111—r,a 7 Stop Time Received Cold j <br /> Hours Custody Seals <br /> Client Sign-off <br /> White Copy - Admin/Lab Yellow - Mobile Lab Pink -Client <br />