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Ultramar Inc. <br /> BEACON <br /> CHAIN OF CUSTODY REPORT <br /> Beacon Station No. Sampler(Print Name) Date E..' of)- <br /> orm No. ' <br /> 6 ANALYSES11-11-2w <br /> Project No. Sampler(Signature) <br /> qa- 12 <br /> Project Location Affiliation c ^ <br /> .N � a <br /> UUil <br /> o <br /> Sample Noildentification Date Time Lab No. n. z° REMARKS <br /> M W <br /> W-17 �3 951 <br /> /A 10453 <br /> W- 5 9 <br /> Relinquished by:(Signature/Affiliation) Date Time R e' ed :(S ignature/Affiliat' Date Time <br /> 401 '." J <br /> 40, <br /> ikhv C�/J <br /> R y:(Signature/Affiliation) Date Time road by: ignature/Affili ion) Da a Time <br /> C' t <br /> K. SP G/o zj o�a> <br /> em. <br /> inquish y:(Signat e/Affiliation) D to Time Received by:(Signature/Affiliation) Date Time <br /> Report To: Bill to: ULTRAMAR INC. <br /> 525 West Third Street <br /> Hanford,CA 93230 <br /> Attention: ��' 5� 4A u <br /> WHITE: Return to Client with Report YELLOW: Laboratory Copy PINK:Originator Copy <br />