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unmmar Inc. <br /> BEACON <br /> CHAIN OF CUSTODY REPORT <br /> Beacon Station No. Sampler(Print Name) D to Form No.! <br /> / ANALYSES Q �f 1 <br /> Pro'Prood No. Sample n ture <br /> w 0q_1 - r <br /> Project Location Affilia n r , <br /> R ! o C <br /> •,,� r w m o <br /> = T o <br /> Sample NoAdentification Date Time Lab No. z REMARKS <br /> - 6-3 3, 1416 )VO <br /> rJ <br /> IM <br /> -� 13 - w3 adze ,1 <br /> i <br /> q11 13 s- <br /> i <br /> Relinquis �y:(S naa/Afliiiation) Date Time Received by:(Signature/gffiliation) Date Time <br /> _ `1rj �( 1 i t J r <br /> Relinquished by:(Signal re/A i tile. MmeW_��eceiid by:(Signature/Afliliation) r D to Te <br /> f ,jReli uis y:(Signa u ifilia ion) �' o Date Timed by:(SigraturelAffiliation) Dale Time <br /> Report To: ff Bill to: ULTRAMAR INC. <br /> 1•'AA 4- 1 525 West Third Street <br /> riR�';;�( Danford,C,193? 17 � <br /> Attention: (3{r; „) .... .. �...�,._... ... , ...._ <br /> WHITE: Return to Client with Report YELLOW:Laboratory Copy RINK:Originator Copy 324W3 ISO <br />