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i <br /> ❑ Yes <br /> Fax copy of Lab Report and COC to Chevron Contact ❑ No Chain—of—CuSfod ""Record <br /> Chevron Faa lty Number- 9-0342Brett Hun Ler <br /> .. Chevron Contact (Name) <br /> Fodity Address_ 1347 S B1 Dorado St , Stockton, CA (phana) (510) 842-8695 <br /> Chevron 11 S A. Inc Consultant Project Number 1;41tzz—?—�i <br /> P o 8�x 5004Loborolary Name Superior <br /> ConeuRant Name Blaine Tech Services, Enc Laborolory Rebase Nambsr 4304880 <br /> San Ramon, CA 94583 985 Pimodiv Dr , San 10SL, CA 951,33 <br /> FAX (415842-9591 Addren Snmpla■ Conected by (Nome) <br /> Project Contact (Name) Jim Keller Contotton DQ4 IIIz q <br /> I <br /> (PhoneYj08 _995-5535 (Fon Number)1H—Z3---8773 Signature <br /> An*vse To Be Performed <br /> a �' a DO NOT BILI. <br /> <o els z � E eFOR TB-LB <br /> po �yj n VUa S + <br /> +9 CN, <br /> cn yN •V �1D D_ a <br /> Ma <br /> ;O g <br /> 3 z' 4141 r F rR m Nm 8 aa� �` G1` ick `2 RamoAu <br /> Mw-3 3 W Iy�1S ►kL 7 '� <br /> -3 V IyZS t Y K <br /> TB b <br /> ter, <br /> _ I <br /> a Regnqulehed By (Signature) Organization Dats/ilme R S1 Organization Dote%Tlme Tum Around Time (Clrcte Choloe) <br /> LL9I 94! Ito —�L�R q4 1T1� 24 We <br /> u <br /> BY (Signature) Organization Date/llme RenNad DY (Slgnnlun) Organization Dat►/Ttme 4e }lra <br /> Ac�Rp 11 i 5 N s Dap <br /> X 1 D Deye <br /> 2S RsllnqulahW By (Slgreturp) Orgonlxolton Date/alms Rec1n For Laboratory Dy (Signature) Date/time M Cantrooted <br /> - _-— l�,� <br />