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A & L WESTERN LABORATORIES, INC. <br /> 1311 Woodland Ave. #1 • Modesto, California 95351 • Phone 209-529-4080 <br /> CHAIN OF CUSTODY <br /> Client Cy�Snl6k alyi I/Z %/ /) Phone 0? <br /> Address 0 UOX ? 7yL/ CC to: <br /> T/r R/ OGl! �f4 Zip <br /> Signature of person authorizing work <br /> under terms stated below' &I <br /> 'Net 30 days. All accounts past due will be subject to interest charges of 1.5% per month. <br /> 'Hazardous materials are the property of the client. The client is responsible for proper disposal of hazardous wastes. Clients not <br /> picking up hazardous wastes may be assessed an appropriate fee. <br /> PROJECT ID Na AN/Y///Z <br /> of <br /> QDST ComSAMP BY: ( ure): tainersREMARKS <br /> Sample <br /> type Sample Location �J <br /> Date Time Ori �„0 <br /> 3033/ Lp JE E i X FiZOy/ SINK <br /> ILA UCE7- Na 4 v(U<F_ <br /> L0NF -fe*E Z � <br /> a <br /> RelipAuiihed b ure): Dilate TimeI 9acisivep by(signature): Date Time <br /> Relinquished y(signature): Date Time Wceived by(signature): Date Time <br /> Relinquished by(signature): Date Time Received by(signature): Date Time <br /> Relinquished by(signature): Date Time Received by(signature): Date Time <br /> Relinquished by(signature): Date Time Received by(signature): Date Time <br /> Site Time: Driving Time: <br /> Start: Finish: Total Hours: Start: Finish: Total Hours: <br /> Dedicated Exclusively to Providing Quality Analytical Services <br />