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=low i <br /> 1 <br /> 720 Olive Drive, Suite D <br /> .�� Davis,CA 95616 <br /> Lab 530 297 4800 <br /> ANALYTICAL ccc Fax 530 297 4803 Lab No Z 7 Page I of <br /> Project Manager Phone No <br /> S© 56 Chain-of-Custody Record and Analysis Request <br /> Company/Addresspp .00 <br /> 0 g6 FAX No + j 4- 1 or- A For Lab <br /> fl el ti p!-f O v a-fi c 3 S H Analysis Request use only <br /> Project Number P 0 No Email Address x <br /> g Ma a <br /> 13pdf ❑ xis Eldoc ❑other u' <br /> Project Name/Location Sampler Si nature <br /> m o W C n M n <br /> top fc to STG G �° a� m m <br /> ontalWer Method o N M <br /> cc M <br /> Sampling (Type/Am unt) Preserved Matrix 0° m 10 m = x $ N v c M a a a 0. <br /> g 2 a a cv cr � 3 n L rn <br /> y O E tw H N rn m <br /> =0 °m m > ao ` w ' mw <br /> ctSamnle M co ID <br /> oc <br /> z ' <br /> u n u n <br /> u <br /> Designation Date Time v n = U a m ° ° ° N N n <br /> C r -or� ! 3 —0 <br /> vlr — -55 -03 <br /> w — is -01 <br /> io <br /> V w - 10'21 -'06 <br /> Relmqui Date Time Received by Remarks <br /> Reli el)6 Date Time Received <br /> Relinquished by Date Time Received by Laboratory Bill to <br /> Distnbution White-Lab, Yellow-File,Pink-Onginator COC fhb(5100) <br /> i <br />