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M� m = M = - <br /> BSK Log Number ANALYSIS REQUEST IC OF CUSTODY RECORD <br /> Client Name Prole; <br /> role or PON q Analysis required <br /> t, !r Lab Use Only <br /> Address P ne N in this <br /> 2 <br /> Cit y4!OCI.2 section <br /> City State Report,Mention <br /> ��fus�lfavllyooe <br /> Date Time RR2 Sampled by C Number Lab pse f I <br /> sampled sampled of Sample Seal <br /> below] Sample description containers number (See key <br /> below] Remarks <br /> far y o3 p O {� �� D T" x <br /> �e �7 5" ;26 <br /> !!SD -tel/ �y�t' �3' x <br /> IMPORTANT NOTICE No samples will be analyzed without an authorized signature in this section <br /> I am hereby requesting BSK s Normal Chain-d-Custody Procedures for the above samples I understand that I am hereby requesting BSK's Formal Cham-oi-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 seance ment of Work Section F and that there is a charge of$5000 per work order or$500 a bottle whichever is <br /> greater <br /> ByfZ" By <br /> Authorized Signature Authorized Signature <br /> Signature Print Name Company Date Time <br /> Relinquished by <br /> Received by <br /> Rehm'fished by <br /> Received by <br /> Pelmquished by j <br /> Received by <br /> r�1..�✓� lKEY Type AQ-Aqueous SL-Sludge SO-Soil PE-Petroleum OT-Other <br /> Seals P-Present A-Absent B-Broken <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) 485-8310 • Fax (209) 485-7427 Hazardous samples will be returned to client or disposed of at client expense <br />