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Cas) 3z 7 <br /> � C ��`�� 'n of Custody <br /> y <br /> Please Print in pen Page of <br /> Client: Tel #: C�>�` CX3 -. G Fax #: <br /> Address: S c97c9s /d, 1 City: State: OIZip code: r�2 <br /> Bill to:0�' ,L [r ,s('�'/j An ysis Items <br /> Project Name/Code in Job #1, 03 P.O. # White-With report <br /> Project Address APCL Quotation # Yellow-Lab copy <br /> Due Date: ❑regular rush: days —hours Sampled by: (X./lh Pink-originator <br /> Field Sample Sample Date Time Sample Preser- # of I ' <br /> 1D No. Description <br /> Collected Matrix vation Containers Remarks <br /> �Z 0,_�7--/-60 S i ZIT « ,c <br /> Tr <br /> I G <br /> C ;9 R11 12 <br /> QC Requirement: 12ftegular; ❑QA/QC Report; ❑WIP; ❑Raw Data; ❑Extended Raw Data ❑CLP; DACE ❑AFCEE ❑NEESA_(E,C orD); E]Other (Please specify) <br /> Sample Disposal: ❑Return.ZDisposal by APCL ❑Fold for days after receiving date. If not specified,samples will be discarded 45 days after samples are received. <br /> Sample Conditions: ❑Intact; ❑Broken. Cooler Seal: ❑Intact; ❑Broken; ❑ None . Tag # Temperature: ❑ Room ❑Cold( °C). <br /> Relinquished by f to/Timeg�y ��f/fJ Received by a4-, Date/Time100 <br /> Relinquished by Date/Time Received by Date/Time / <br /> APCL USE ONLY Servicer Note: <br /> Clients understand that all terms described in the proposals,quotations for this project, and/or the general terms provided in the current APCL price schedules will be followed. APCL reserves the right <br /> to terminate its service or withhold delivery of any reports,if in APCL's sole discretion the terms of the project have been broken. <br /> APCL F—M 4.101,Ver, 1.0, Dec.70, 1991. Ftnot.file:[CUST.DATA.LAB]CHAIN—FLOOT.TEX FHe:[CU5T.DATA.LABICHAIN4.TEX <br />