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111111111slM M M = M " = 9 = = = M M M <br /> 720 Olive Drive, Suite D <br /> .�� Davis,CA 95616 <br /> Lab 530 297 4800 <br /> ANALYTICAL Lic Fax 530 297 4803 Lab No ZY`?2-3 Page I of <br /> Project Manager Phone No <br /> To 0- Ra m q ytr Cgs 5 -32 So Chain-of-Custody Record and Analysis Request <br /> CompanylAddress FAX No F <br /> K' "41t (m) 3S4- 11 $ 6 Analysis Request F <br /> Project Number PO No Email Address m x <br /> ❑ pdf ❑ As ❑ doc ❑other <br /> Project Name Sampler Signature" ? ? m c V1EO X <br /> Var"er S�� �a�n G'q� S N N p <br /> Project Location °� 00 m m m a o w <br /> I'�i9 s C grter Way S CGKt4y o 7 0 0 o N v y <br /> — a s N °3 a J ° N m <br /> Sampling Container Preservative Matrix — o t m w N �+ L � <br /> _� <br /> O = 0 in c c a to N LL <br /> Sample W �, u, �, M 3 N <br /> Designation o �' F z° LU o ¢ o a s �a a o 0 0 <br /> Date Time v m _ z to m m <br /> CPT iA - 60 9Z0 4 X w x X x 1 -o <br /> CPT1A - 105 1005 x x W x X x —d2 <br /> CPT2 - 64 2111ax 045 Lt x x W x x x —o <br /> CPr2- 115 9�0 4 x X w x x x _o <br /> O r2- IN 1020 4 x X w x <br /> Relinquished by Date Time Received by Remarks <br /> Relincklished by Date Time reived <br /> Relinquished by Date Time Received by Laboratory l Bill to Wriq f tviviraiiw wi fit 5iRtCS5, TMC <br /> 1c433 E- 14t"' St Tr cY CA <br /> Distnbuvon White-Lab Yellow-File Pink-Onginator M �alit q, �8 j dr (1.09)513-01;V F...I .os2aa�4h9 <br />