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eS1c Log Number ANALYSIS REQUEST/CHAIR CUSTODY RECORD <br /> 1?'� <br /> Client Name Project or PO <br /> C ` 1 Analysts required <br /> Address Phone it Lab Use Only <br /> Qvar / <br /> in this y <br /> City State 1G Re �( ` OQ� section e` <br /> �p port,attention / <br /> �tls-r4A"7-GH f -A el" L / U <br /> IA , <br /> ' <br /> Date Time � Sampled by Sample <br /> Number Lab p / 5 <br /> sampled sampled of Sample Seals ^ ' <br /> below) Sample description Contains number (5®e ;y <br /> Wow) �f t S Remarks <br /> 4 0 #/ App <br /> y d 7 � X <br /> o16S <br /> o� x X <br /> x <br /> —X <br /> K X N <br /> IMPORTANT NOTICE No samples will be analyzed without an authorized signature in this section <br /> I am hereby requesting BSK s Normal Cham-0f-Custody Procedures for the above samples. I understand that I am hereby requesting BSK s Formal Cham-of-Custody Procedures for the above samples I understand that <br /> these procedures are generally consistent with those outlined in the US E PA SW 846 and that there is no these procedures are generally consistent with those outlined in US EPA Contract Laboratory Program State <br /> extra charge for this service t Ment of Work Section F and that there Is a charge of$5000 per work order or$500 a bottle whichever is <br /> B Au greaterY eYrized Signature Authorized Signature <br /> Signature Print Name Company Dale Time <br /> Relinquishedb4 !► �v e— <br /> Received by, � L_„ ■ � i, <br /> `f/�-tid' btu /7" <br /> -i& <br /> Relinquished by <br /> Received by <br /> Relinquished by <br /> Received fry <br /> S <br /> KEY Type AQ-Aqueous SL-Sludge SO-Soil PE-Petroleum QT-Other <br /> Jli(\ Seals P-Present A-Absent B-Broken 1� <br /> & Associates Chemical Laboratories DISTRIBUTION WHITE CANARY LABORATORY PINK ORIGINATOR <br /> Note <br /> 1414 Stanislaus Street Fresno, California 93706 Samples are discarded 14 days after results are reported unless other arrangements are made <br /> Telephone (209) 485-$310 • Fax (204)485-7427 Hazardous samples will be returned to client or disposed of at client expense <br />