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CW IN OF CUSTODY REWORD <br /> t <br /> SAMPLER (signature): i <br /> Phone: 4 3255 Mission Blvd. 5uwte B Fremont. CA 44539 1415)651-19fk <br /> LABORATORY: SHIPPING INFORMATION: <br /> ., 4:�� �;,t,� �— Shipper <br /> Address <br /> Date Shipped <br /> TURNAROUND TIME: It ss Service Used <br /> Attention: � Airbiil No. Cooler No. <br /> Phone No. NIS) <br /> Relinquished by: (signatures) Received by:(signatures) Date Time <br /> � t Lt 86 `t:ocS <br /> Received or iaborstory <br /> If-21- <br /> LABORATORY <br /> 1-LABORATORY SHOULD SIGN UPON RECEIPT AND RETURN A COPY OF THIS FORM WITH THE <br /> LABORATORY RESULTS <br /> Sample Site Date Analyses Sample Condition <br /> NO. Identification Sampled Requested Upon Receipt <br /> w•So.+Nw4A ��q\-�-1 ilZl• 'S'6 cx�.ewc��� �Gc pct <br />