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CHAIN OF CUSTODY RECORD AND ANALYSIS REQUEST S H(jlp <br /> 44 I Ll <br /> 5500 Boscell Common Fremont CA 94538 Tel 510 490-8571 Fax 510 490 8572 <br /> Project Manager A )- BIII to <br /> 0AfS1r.=. <br /> E N V I R O N M E N T A L Client Name } Company <br /> LABORATORIES, INC Address QC) Address <br /> City, State ZIP Q! City, State ZIP <br /> Phone �' Phone <br /> Date /Qq Fax r Fax <br /> Page 2 of ;L— <br /> Laboratory uw 5,1e k wv Protect Name P O No <br /> Lab Number 2 Fat(, Protect Number fj 11i _ CJ <br /> Analy is Requested <br /> a Ln <br /> T <br /> EA �O m i' <br /> 06 L C m '4 " <br /> U T � W <br /> X 1� V <br /> Sample Identdicalron Date Sampled Time Sampled Matrix JID a y Remarks <br /> ,_ / �-/V �t/ /S 30 MY zl04- <br /> .t. S ys� l6/� Ib/G - �/ Z <br /> Initials Printed Name Signature Date Total Containers <br /> p{�f ",Ckkf Qk 4ra-'ii4 `► � `�� , Start Time Received Intact <br /> gal' 7�Jr Stop Time Received Cold <br /> Hours Custody Seals <br /> Ilet Sign-off <br /> r j"a r"WArInnWh Y - 11rWW ah b* f liNjN M ' _ <br />