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Uitraftr Inc. <br /> r" BEN <br /> CHAIN OF CUSTODY REPORT <br /> Wlram r <br /> Beacon Station No. Sampler(Print Name) Date Form No. <br /> ANALYSES -10�� / of <br /> Project No. Sampler(Signature) <br /> /900 �� �r/•�� /c'�'�' _ `� <br /> Project Location Affiliation a <br /> 21�d f' r F'�m or.f S f'• �ry� / 0 <br /> x �, o 0 <br /> W z T. ° S f-gr��cr TI}T <br /> Sample NoAdentification Date Time Lab No. m CL C z° REMARKS <br /> /Y W- -_s /D306'm <br /> 45 <br /> real <br /> Relinquished by: (Signator /Affi' tion) Date Time Received by: (Signature/Affiliation) Date Time <br /> ZU <br /> �%'/�,�� • I�`�� SS's <br /> Relinquished by: ignature/Affiliation) Date Time Received by:(Signature/Affiliation) Date Time <br /> Relinquished by: (Signature/Affiliation) Date Time R eived A( , ure/Affiliation) Date Time <br /> V <br /> Report To: Bill to: ULTRA AR INC. <br /> T 525 W st Third Street <br /> U�� Hanford A 2 <br /> J w � C 93 30 <br /> A�1/ /'>C Attention:__fj!._ <br /> WHITE: Return to Client with Report YELLOW: Laboratory Copy PINK: Originator Copy 72�� � <br />