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D U ❑ E Chain - of - CustodyForm - Page ) of ! <br /> 605 Third Street Laborato GS.'4i _ Lab Job#: <br /> Encinitas, CA 92024 Lab Contact: 61;-Vlt1r6� Shipping Methd• CUIzfGfC-YL <br /> Tel:760-942-5147 <br /> Fax:760-942-5206 Project Manager: r�J PM Email: <br /> @dudek.com <br /> Project Name: Job Number: / Tvoe of Anal sis to be Performed TAT Special Instructions <br /> 0o O Q _ v <br /> N N N 00 <br /> O O <br /> Sampled by: /v`/,'1:0e Sampler Signature: "Y Q ¢ Q Q o <br /> W W W W W 00 <br /> N C v <br /> Sam le Collection Matrix Method Preserved umber of Sam le Container 2 o d N <br /> h a <br /> ti <br /> z C <br /> o <br /> w b a a <br /> °zm o ¢ o Q o o x y <br /> Sam le ID Date Time ° = = z i£ O / O � U H Q C <br /> 10131 1 10 A <br /> t®l31 0501 X X /14 Z x <br /> - 1 10/3) t 10 n 191 X 3 1f <br /> x !X 3 <br /> s w-� 0/3( )i1O Aa 'X 3 Z <br /> Sti(GV-Z 10121 11323 x Z X X <br /> k 0f3! J 52- !�' x X <br /> r 0(3 15-53 X X 4 3 z x <br /> Total# of containers per type Z Total#of containers V 3 Please return original COC to Dudek <br /> Relin `ic d b m Ti ff- anDat Tim am le Recei t <br /> l f- i {� �� ❑ Samples Intact <br /> f_ <br /> ❑ Cooler Temp: oC <br /> ❑ Conforms to COC <br /> R �11/15 <br />