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H.b. Diztz and Associates CHROMALAB FILE # 1092047 <br /> 8617 Etcheverry ORDER # <br /> Tracy, California 95376 CHAIN-Ol <br /> ( 209) 832-2910 ( Sawe FAx"t� 11&1VALAa <br /> PROJECT NAME/NUMBER ''�`" � <br /> LAB DESTINATION 674 <br /> SAMPLE TEAM MEMBERS �" � =� CARRIER/WAYBILL NO. ''� <br /> To Laboratory: Please return completed record. <br /> Sample Sample Date & Time Sample Container Condition on Receipt Disposal <br /> Number Location & Description Collected Type Type (Name and Date) Record N^. <br /> � I <br /> i <br /> f j <br /> Special Instructions: L`'� _ ,�' T �f T,Ct-O i <br /> Possible Sample Hazards: <br /> SIGNATURES: (Name, Company, Date and Time) <br /> 1 . Relinquished By: ZI <br /> /�_4Lu� 3 . Relinquished By: <br /> Received By: fl Z Received By: <br /> 2. Relinquished By: 4. Relinquished By: <br /> Received By: Received By: <br />