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CHw..�V OF CUSTODY RECC., ® 57bq <br /> Mr. G/cran Oemorn{� <br /> SAMPLER {signature): / --Q"�— <br /> A,cta/ie� GsoSyst�ms <br /> 4 ` ' 4191-E Power Inn Road.Sacramento,CA 95II25 MIS)452-29M <br /> Phone: •Fremont •Costa mesa .Sacramento <br /> LABORATORY: SHIPPING INFOlRMATIONP <br /> a r- o S Shipper FP�rr/c I- �prt�5 <br /> 11A,'nm <br /> c-• Address <br /> R 12 'IdG Date Shipped <br /> TURNAROUND TIME: $erY1Ce Used <br /> LcJCS(ne Vit::7T.�tL <br /> — ~ <br /> Attention//: ' �' Airbiii No. Cooler No. <br /> Phone NoL�« ' <br /> Relinquished b sigh ures! Received by:(signatures► Date Time <br /> 1.y <br /> be ed for isoat by: <br /> ABORATOR'r SHOULD SIGN UPON RECEIPT AND RETURN A COPY OF T HIS FORM WITH THE � <br /> LABORATORY RESULTS <br /> Sample SIte Date Anaiyses Sample Condition <br /> No. Identification Samaled Requested Upon Receipt <br /> -s3—Mev t �z T G):9TEY(q-N.) -17777..�� <br /> L.J-53-MW3 Qi � � <br /> (,V-S.z•MW`� ice. 04 <br /> w:�js 2aaaL-2— -/I za T'tl/J, B Te X, f'kn3,1 <br />