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i <br /> unramar Inc. BEACON <br /> uwrerrr <br /> CHAIN OF CUSTODY REPORT <br /> Beacon Station No Sampler(Print Name) PatForm No <br /> D S S ANALYSES )MIL I. of <br /> Protect No Sampler(S�nad <br /> Nri o <br /> Pin VAIs AT 3� . <br /> Protect location Z <br /> Affiliation <br /> .� Fart "i1Pta t.a�tsso at: <br /> ti b5 !:. t=►�..1c.K�aw�S1. � <br /> m � p <br /> w X_ 2 o SQA W> Dr�Q <br /> Sam a NoAdentification Date Time Lab No m a z° REMARKS <br /> ��1D4�� � s I�1�►s )aZ� � �� -x�t��.. ��� BAS <br /> AL <br /> mV�l 3 I wq" PRE S <br /> I <br /> Relinquished by (Signa reJAffihation) Date Time Received by (Signature/Affiliation) Date Time <br /> z0A11F1Ate.)I:Ljc,. M-96 6 .� Avt t-kAs 16,0 <br /> Refmqutshed by (SignaturelAfliation) Date Time Rete by (Sign ture/Affiliation) Date Time <br /> rW E,57- Vtz/4-t7 <br /> Reb uished by ( ignature/Af6lialion) Date Time Receiv y Signature/A drat:on) Date Time <br /> I�IAS 175 <br /> Repon To Bill to ULTRAMAR INC <br /> 525 West Third Street <br /> Hanford,CA 93230 <br /> Attention k. �rif�TIES� <br /> WHITE Return to Client with Report YELLOW Laboratory Copy PINK Originator Copy �� <br />