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M2�BSK Log Number � ANALYSIS REQUEST/CFIA� CUSTODY RECORD <br /> Client Name fJ1 �,y py Prolefr PON �{ Analysis required <br /> 4?e 16Phone N Lab Use Only <br /> Address t <br /> / 1 <br /> vavG' In this <br /> Z01 p section <br /> Cdy State Report attention 4 - { bA <br /> Sampted by / <br /> e r✓`� Sample ` y <br /> Date Time TyQe [T Number Lab ] J <br /> sampled sampled See of Sample seals <br /> below) Sample description rontainers number (S-key ( m <br /> below) \ Z�y`� Remarks <br /> L149 f So o�' i� �o f <br /> ! # t zD <br /> /Y l0 <br /> IMPORTANT NOTICE No samples will be analyzed without an authorized signature In this section <br /> I am hereby requesting BSK s Normal Cham-of Custody Procedures for the above samples I understand that I am hereby requesting BSK s Formal Chain-of-Custody Procedures for the above samples I understand that <br /> these procedures are generally consistent vnth 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 ment of Work,Section F and that there Is a charge of$50A0 per work order or$5A0 a bottle,whichever is <br /> ` greater <br /> By By <br /> Authorized Signature Authorized Signature <br /> Signature Print Name Company Date Time <br /> Relinquished by ; <br /> Received by i <br /> Relinquished by <br /> Received by <br /> i <br /> Relinquished by <br /> Received by <br /> BSKEY <br /> K <br /> Type Aft-Aqueous SL-Sludge SO-Soil PE-Petroleum OT-Other <br /> Seals P-Present A-Absent 8-Broken <br /> & Associates Chemical Laboratories DISTRIBUTION WHITE CANARY LABORATORY PINK-ORIGINATOR <br /> Note <br /> 1414 Stanslaus Street Fresno, Califomia 93706 Samples are discarded 14 days after results are reported unless other arrangements are made <br /> Telephone (109) 485-8310 o Fax (209) 485-7427 Hazardous samples+null be returned to client or disposed of at client expense <br />