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'FChai:.rf Custody Form MI(' J ANALYTICAL LABORATORI') INC. <br /> �1w 1046 5400-Hollis Street, Suite mi, Emeryville, Cali fornia`44608 szzzx <br /> Name I Client I Address: (510) 653-0824 - (510) 653-1361 - FAX <br /> FP,-.ng Pow Project <br /> Innovative& Creative Asbestos i <br /> '� TEM PLM PCM <br /> Environmental Solutions- _ Lead Only <br /> P $ox 2 TTLC(Total STLC TCLP <br /> 88 Metals <br /> Emeryville.CA 94 62 (Specify) TTLC(Total) STLC TCLP <br /> Other <br /> Tel.— (510)652-3222 P.O. No. <br /> Fax (510)652-3555_- _ Number of Samples <br /> ' ;I r i <br /> Turn Around Time ry OV w1�+r �R S) <br /> Matrix Type Bulk Dust Paint Soil Wipe Air Water Other <br /> Time Sampled <br /> Date Start/Stop 1 Average Total Filter <br /> Micro ID# Client ID# Location I Description Sampled Total Minutes LPM Liters Pore Size <br /> I � <br /> Instructions: * p�cRsc ScY1� A %oP�/ 07. �l'lalyTlGc1� Y. XV s Wt-Ci -tvs mlelm'l F. ki�� <br /> ImbIIC' +1=-41�h s'-yV1, <br /> Sg11J0.1 1!!Y) Gouh l <br /> � A V <br /> �p <br /> Sampler's Sign ture / Name 3r� YY�C� <br /> d f 3 -orb 6 �. <br /> Drop Box 1 u S` i��k��►, c�. c[52—v-4 <br /> Relinquished By Date/Time Receiv By Date/Time <br /> Relinquished By Date/Time Received By Date lTime <br />