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CHAI "I CUSTODY RECD <br /> I � <br /> NIPPER (signature): <br /> Applied GecSystefrms <br /> i <br />'ane: G1 2. 33253 ilia.stein Blvd. Suite B Fremont. CA g45.19 (4151651-19x16 <br /> BORATORY: SHIPPING INFORMATION : <br /> Shipper <br /> Address <br /> Date Shipped <br />�RNAROUND TIME: �8 �p "�-� Service Used <br /> E } <br />!entlon: Airbill No. Cooler No. <br /> Pne No. 0 7- <br /> IIuished by: (signatures) Received by:(signatures) Date Time <br /> 2:3a } <br /> Received laboratory by: 17 <br /> SORATORY SHOULD SIGN UPON RECEIPT AND RETURN A COPY OF THIS FORM WITH THE f <br /> LABORATORY RESULTS <br />;ample Site Date Analyses Sample Condition <br />'. No. Identification Sampled Requested Upon Receipt <br />' D9ZD — S` 87053- 1 TX, 7v,�11 <br />