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3r '• �� �Y �°'� Vii+ _ r' .r 1 _ �`,`>ri _ } ~� a_°3+}'�i _ <br /> ilL"I oy Nurduir —'-- <br /> CHAIN OF CUSTODY RECORD --- <br /> _ w E't7 <br /> Chen]name •5-3,VO <br /> Addross <br /> y m . <br /> fiepal aitcrn.r r• 'V' �i.� <br /> Cuy,Sta!o.Zip <br /> J e it <br /> F, r,. 5:cmph:d t]y riuniui:r �7 ��5 <br /> r7t�Ll[ <br /> Sarnplu (WoTune Sen luf cunlun,er5 h <br /> numbor samplud sarnpled here++ Sempic deecnpuurr <br /> =1/71 jy3,5 W- <br /> .I 170 V-16 <br /> II logo <br /> Date Time <br /> Company <br /> Signature C L� Print Name <br /> Relinquished by .:/ .P i!l►'r R� LI•r ? 6. <br /> Received by -- <br /> Relinquished by — <br /> Received by <br /> Relinquished by <br /> Rer.eived by labdratdry <br /> Note: <br /> BROWN AND CALDWELL LABORATORIES Samptes are discarded 30 days cher reruns are reported unless other arrangements are made <br /> ❑1255 P4e1611 Streal.Emeryville.CA 94608(4151428-2300 Hazardous samples wdr bo relurnad to client or disposed of at client e.penso. <br /> ❑773 South Fair Oslo Avenue.Pasadena.CA 91105(818)795.7553 •KEY. AO—Aqueous NA—Nonaqueous S1--Slud90 GPI—Groundwaler SO—Sar OT—Other PE—Peuoleum <br /> []t200 pacifice,Avenge•Anaheim.CA 92805 <br />