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_� DeMennolKerdoon <br />"Rrrgrling F'nr A Clean er E'twirunmenf" <br />s s 2000 North Alameda Street • ('nmpton. CA 90-222 <br />(31(453;-7100 Fax: (.310) 630-12,54 <br />(A -DIN EIAPCartyk-ate x103;- <br />Date <br />Chain oJ- " tstocry <br />1-17-11 Page --- ( qt- I - <br />Client: Contact: <br />act:N Tel— 747'-- �— ---- <br />Fax: -- <br />to <br />Address:— -- - <br />S-I.J City: -SState: Zip Code: �SZ06 <br />Project Name: - — Sampler(s)-- — <br />Signature: <br />Project Manager: , t <br />Due Date ❑ Regular ❑ Rush Days <br />Approved By: <br />Comments: <br />Sample Description <br />Lab <br />ID <br />Date Time <br />Collected <br />Matrix <br />No. of <br />Containers <br />Analysis Requested <br />S -0 'z_- <br />- — <br />21 -D <br />-- — <br />a n-1 <br />- <br />i�:��.., <br />_ <br />s'•l�d <br />-- <br />ICA <br />— <br />wiGas-Di-vt - a' 01. - <br />T— : An A-ttIlly._- <br />Ourltpie uonumons: ,peal j intact <br />Relinquished by 01; y(m ttzwe) <br />Relinquished by (Signature) <br />Relinquished by (sigti(Itur ) <br />SPECIAL INSTRU ONS <br />IJ None; Temperature ❑ Cold (❑ Room; Other <br />Received by <br />Received by <br />Date/TiTne -7 <br />Date/Timed -/7-1,(, - 7 loo/ <br />Received by (Siynatu e) '` Date/Time <br />WHITE COPY—Client PINK COPY — Courier <br />