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Vltrartrar Inc. BEACON <br /> CHAIN OF CUSTODY REPORT <br /> FuMmwMa1nnmWw <br /> Beacon Station No Sampler(Print Name) Date Form No <br /> ANALYSES -17 7 1 R of <br /> Project No Sampler(Signature) <br /> -6q5 - 01 <br /> Project Location Affiliation <br /> A <br /> Sample Nolidentification Date Time Lab No m �a n=. z°1 REMARKS <br /> W- 1 2' 3-�7 a.o0 3 -11 <br /> W <br /> Relinquished by (Signature/Affiliation) Date Time Received by(S nature/Affiliation) Dat Time <br /> R quashed by ( i ture/Affdiation) Da Time Received by (Signature/Affiliation) Date Time <br /> t�� �S 47 1630 <br /> Relinquished (Signature/Affiliation) Date Time Received by(Ssgnature/Affdiation) Date Time <br /> Report To Bill to, ULTRAMAR INC <br /> n/ <br /> j 525 West Third Stree <br /> AO—e-,, Hanford,CA 93230 <br /> Attention <br /> WHITE Return to Client with Report YELLOW Laboratory Copy PINK Originator Copy <br />