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- -t entrum f�na! i�al La,6oratorres Inr.� �.. Centrum Job <br /> 290 TENNESSEE STREET (909)798-9336•(B00)798-9336 Chain of Custody Re� rd 2 <br /> REDLANDS,CA 92373 FAX(909)793-1559 Page Z of <br /> XAnal ses Rec Liested <br /> Project No.: Project Name: dom { <br /> p a Turn-around time <br /> SA)cjanJ /SIA!vU 1-6AJ4 Cl Q5- C•'Cj (D,A� N v o 1= <br /> N N m L 0 24 Hr. RUSH' <br /> Project Me.nager: Phone: Fax: v W <br /> o CL <br /> � c m E48 <br /> ur. RUSH <br /> ' <br /> DCwS l5 !L7�� ❑ Normal TAT <br /> Address:Name: R•qim prla appov <br /> l,y <br /> (company) /y�{. C N c `0 U addticralchwr osapply <br /> -� ' w �. �-o,A)1C7M1J 16�/lig p 1 IiO� � 7 T� � p a � � ri U � t—i <br /> v m Remarks/ <br /> Centrum ID Sample ID Date Time Sample Containers: ri a r w 0 <br /> Site location #and type cco 31: b Special Instructions <br /> (Lab use oniy) (As n should appear on repod) sampled sampted matrix <br /> 0 40 clo a- u_ <br /> v(IAS <br /> �i M w - z 12/5l T 7.5!91P-,_b I AMAe y <br /> / 17 <br /> L0: 3 !` <br /> Ni V <br /> Zc3vedby� <br /> �y: am els Sign tura Date Time Relinquished by: Date Time <br /> � To be completed by laboratory personnel: Sample Disposal <br /> � 7 °'�pate Time, Received by: Date Time Samples chilled? Yes f]No <br /> " [3Ciient will pick up <br /> Custody seals? ❑Y..IVN. <br /> Relinquished by: Date Time <br /> All sample <br /> The delivery of samples and the signature on this chain of custody form containersYes C}No El Retum to client <br /> � Intact7 <br /> constitutes authorization to perform the analyses specified above under Dat Time ❑Cour LtP51F�d x L]Hand carried <br /> Receive for Laboratory by: ❑ Lab disposal fee$5 <br /> Mu TounS ar7d Conditions sot forth oil ihu back huroof. - / <br /> 1ob&12!�f <br /> Sample Locator No. <br /> Laboratory Notes_ <br /> Pink Copy <br /> White Copy-Original(Accompanies Samples) Yellow Copy-Centrum Files -Client Copy <br />