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Wk-9 t -ANAIRS REQ TIClfOF MCUSTODY MRECORDM7 I <br /> Client Name Prole or PO p q <br /> J <br /> (/7/ �!r 3 Analysts required <br /> Lab Use Only <br /> Address P ne# in this <br /> section <br /> City State Report tenhoAn / u <br /> ll <br /> Lr�f CCl/ff4d1 �G <br /> Sampled by <br /> Date Time c e Number Lab Sample <br /> sampled sampled See k of Sample a <br /> below) Sample description containers number (See key <br /> below) Z g Remarks <br /> 20 <br /> -ala f 7- ?� <br /> L I I I I I I I I I -J <br /> IMPORTANT NOTICE No samples will be analyzed without an authorized signature in this section <br /> I am hereby requesting BSK s Normal Chamof-Custody Procedures for the above samples.I understand that I am hereby requesting BSK s Formal Chain-of-Custody Procedures for the above samples 1 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 U.S. EPA Contract laboratory Program State- <br /> extra charge for this service meet of Work Section F and that there is a charge of$5000 per work order or SSM a bottle,whichever is <br /> greater <br /> ay BY <br /> Authorized Signature Authorized Signature <br /> Signature Print Name Company Date Time <br /> Relinquished by <br /> Received by <br /> µ f <br /> ReliN shed by <br /> RecerAd by <br /> Relinquished by <br /> Received by <br /> BKEY�+�� lype AO-Aqueous SL-Sludge SO-Soil PE-Petroleum Orr-Other <br /> \J Seals P-Present A-Absent B-Broken <br /> & Associates Chemical Laboratories DISTRIBUTION WHITE,CANARY-LABORATORY PINK-ORIGINATOR <br /> Note <br /> 1414 Stanislaus Street Fresno, Califomia 93706 Samples are discarded 14 days after results are reported unless other arrangements are made <br /> Telephone(209) 485-8310 9Fax (209) 485-7427 Hazardous samples will be returned to client or disposed of at client expense. <br />