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W 1 W <br /> 720 Olive Drive, Suite D <br /> TiAANVtAL <br /> Davls,CA 95616 <br /> Lab 530 297 4800 <br /> TICAL I <br /> 1-LC Fax 530 297 4803 Lab No Page of <br /> Project Manager Phone No <br /> Etlo Iz M TOCf-1 -71 y8 3 6 3� Chain-of-Custody Record and Analysis Request <br /> CompanylAddress FAX No sL For Lab <br /> G O/V 1 ry rV f'f/d. 4 -7/ y 9 3 6 6'6 Analysis Request Use only <br /> Project Number PO No Email AddressiF <br /> m m a s <br /> 9 6 L /—oo l ` "i ❑ pdt ❑As ❑ doc ❑other $ LU <br /> Project NamelLocatton Sampler Signature <br /> a a <br /> l!1 1iL C C N M V3 <br /> C(VO N <br /> ContAff ° <br /> Method w m o w ° 8 ° <br /> Sampling (Type/Amount) Preserved Matrix m �_ = i m N Q a a <br /> od :3 <br /> IL CL <br /> N O C m C r r <br /> O <br /> Sample <br /> z 3� q M 11 O p <br /> Designation Date Time a co z x z Lo t o w N N NIWO <br /> Wri i3 3 <br /> 147 ,�pZ <br /> w <br /> 1,01 <br /> —a3 <br /> wo r <br /> -coq <br /> i5a --� <br /> Relinquished by Date Time Received by Remarks <br /> Relinqu ed by D ece�ved by <br /> Relinquished by Date Time Received by Laboratory Bill to <br /> L/ L o Al <br /> Distribution White-Lab Yellow-File Pink-Originator t_ COC fhb(5100) <br />