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180 BLUE RAVINE ROAD, SUITE 8 <br /> AIR TOXICS LTD. FOLSOM, CA 95630-4719 <br /> {916)985-1000 FAX (916) 985-1020 <br />' AN ENVIRONMENTAL ANALYTICAL LABORATORY DU 160C <br /> CHAIN-OF-CUSTOIN CORD Page _L of <br /> Contact Person Project info: - Turn Around Time: <br /> Company — l_''=_'' ' 1 ,'11 t 1[ t L <br /> PO # <br /> Address _? 1, btty �r ) z State� Ztp Sz7 Protect# —1 :31 � ANormal <br /> > - ❑ Rush <br /> Phone _—_?-- `_ _r_ '' FAX 'i 1�, - �.Z 7 7 R[v Y� Specify <br /> Protect Name <br /> Lab Field Sample I D Date & Time Canister Pressure/Vacuum <br /> I D P Analyses Requested <br /> Initial Fnal Receipt <br /> r r <br /> Collected By Print Signature <br /> s = 4r ,% ,! '/• Notes K��U[ TS InI PPy� <br /> Rehnqulshe- �dffyl�9�) Daterrime Received By (Si nature) t]ate`T e <br /> +u A A 1/ 9 <br /> Reli quashed By (Signatre) Date/Time Received By {Signature) Datenime <br /> �. yt �_ \ <br /> flelmqui brit By (Sign dnin) L]�tn time 1`1 ed y (Sr aturelPate/Tim <br /> e <br /> fJ <br /> 10ft WO s \ � <br /> Lab <br /> Shipper Name _ AI Bill # Open60 B Dat rrr Teri *C) Condition Custody Seals Intact? Work Order# <br /> - <br /> Use ! — _ 7 7 1 fr l��s f Doi] �Ii�,?y1� ( fr7 Yes No ane <br /> ' Only <br /> J 1 0 <br /> 1293 rev 05 <br />