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180 BLUE RAVINE ROAD, S[11TE B_ <br /> AIR TOXICS LTD. , FOLSOM, CA 95630-4719 <br /> (916) 985-1000 FAX: (916) 985-1020 <br /> AN ENVIRONMENTAL ANALYTICAL LABORATORY D O 60C' <br /> CHAIN-OF-CUSTODY P&CORD <br /> Page ! of <br /> Contact Person —+'� ` r '± r' I r�►�T- <br /> ---- Project Info: Turn Around Time: <br /> Company ----, P.O. # <br /> _ <br /> Normal <br /> Address _'�1 i i., I,• � _,I_•, If I `-Y L✓ity r''r t { —. State A Zip S-1 Project # ❑ Rosh <br /> Phone -- t. , '. .y - <br /> _� ' �� <br /> - -- -------- ------- --� � _ � � 7 <br /> FAX �a SpecifyLab Project Name R <br /> LD. <br /> Field Sample I.D. Date & Time Analyses Requested Canister Pressure/ Vacuum <br /> Initial Final Receipt <br /> 0 <br /> Call; �- - -... <br /> 0 let <br /> Collected By: Print Signature <br /> Notes: K�sVC r5 In! pPh� <br /> -- --- — Received By:� •% <br /> Relinquished By.,(,G gaature) Date/Time (Signature)-DatelTAC <br /> Relinquished By:(Signa!!�rel uaiemme Received By:(Signature) Dale/Time <br /> r <br /> 1 <br /> nelinqui tied By:(Signalnrcl aare,`Time R ceived Y.(Si�eture) 5eMme <br /> Lab <br /> Shipper Name _ Ai Bill# Open6d B Dat /Ti o. Temp.CC) Condition Custody Seals Intact? Work Order# <br /> - , <br /> Use i' . : : --- -- L Jfyr I�/S� f IDJC avoo, �yuJSr7 Yes No one <br /> Only - <br /> Pnrm 1293 rev,05 <br />