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� A Chain of Custod Form <br /> BC LABORATORIES, INC. UVS-*104 : Y <br /> R1p111 T, <br /> Page <br /> CI en P/(-, Project#: <br /> • ' of r <br /> LComments: <br /> Attn: �)'!� r Project Name: <br /> Street AddressW7 <br /> City,State,Zip: ��j-5 ampler(s): /yJ� O�,S✓G � ,Gt� 1 <br /> Sample Matrix Result Request "Surcharge <br /> Email: <br /> d <br /> Work Order#• �p 3 3 ❑STD 5 Day" ❑2 Day" ❑1 Day— <br /> (10 Days <br /> Dat- A <br /> . \ <br /> C = N <br /> Description <br /> • Sampled Sampled in rn o c7 3 Other Notes <br /> 777 -X <br /> 5-a/c/) <br /> n Same as above EDF Required? Global ID System# <br /> ✓ •/L^ , _� C I/f'C� Geotracker (Needed for EDF) (Needed for EDT) <br /> Client:.-- 4��F J ❑Yes Q No 1.Relinqui had)y Date Time 1.Received By ate }Time <br /> Address Z e�GCt�fi _________ 1 J t <br /> Send Copy to 2.Relinquished By Date Time 2.Received By I Date Time <br /> City: 5 �, >J.t StatQL � Zi State of CA? (EDT) <br /> Attn: 3.Relinquished By Date Time 3.Received By Date Time <br /> ❑ Yes [I No <br /> P.O.#:44w4)V NYUCZSV <br /> BC Laboratories, Inc.—4100 Atlas Ct.—Bakersfield, CA 93308—661.327.4911 — Fax: 661.327.1918—www.bclabs.com <br />