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WORK ORDER Ia l p <br /> CHAIN OF CUSTODY RECORD <br /> qzg <br /> Alpha Analytical Laboratories Inc. • 860 Waugh Lane,H-1,Ukiah,CA 45482 • (707)468-0401 • FAX(707)468-5267 DATE PAGE OF <br /> CLIENT'S NAM PROJECT MANAGER SAMPLE CONDITION ON <br /> 1�Arts LSO �� RECEIPT: <br /> STREET ADDRESS CITY STATE ZIP PHONE NUMBER <br /> COLD/ICED? <br /> PROJECT NAME FAX NUMBER <br /> BUBBLES OR AIR SPACE? <br /> CONTRACT/PURCHASE ORDER/QUOTE NUMBER SITE CONTACT <br /> ��, WERE SAMPLES PRESERVED? <br /> SIGNATURE OF PERSON AUTHORIZING WORK SAMPLED BY <br /> UNDER TERMS STATED ON REVERSE SIDE OF / <br /> FORM. <br /> • • •� • • BELOWTIES EXPLAIN IRREGULARI <br /> � � • <br /> Y.td '� s.s <br /> �. /s.' <br /> A <br /> . .F j•. t Y'V 4y 3 i e. ;, 1 fly y k .. <br /> ` f , <br /> V <br /> RELINQUISHED BY: RECEIVED BY: DATE TIME afilm loll • • <br /> (SIGNATURE) (SGNATURE) <br /> RELINQUISHED BY: RECEIVED BY: DATE TIME <br /> (SIGNATURE) (SIGNATURE) <br /> RELINQUISHED BY; i RECEIVED FOR SAMPLE CONTROL OFFICER <br /> (SIGN4TURE) LABORATORY BY: <br /> METHOD OF SHIPMENT AUTHORIZED BY: SAMPLE DESPOSITION: <br /> 1. STORAGE TIME REQUESTED DAYS <br /> (SAMPLES WILL BE STORED FOR 30 DAYS WITHOUT ADDITIONAL CHARGES: <br /> SPECIAL INSTRUCTIONS THEREAFTER STORAGE CHARGES WILL BE BILLED AT THE PUBLISHED RATES.► <br /> 2. SAMPLE TO BE RETURNED TO CLIENT? ❑YES ❑NO <br /> DRIVWG TIME SITE TIME TOTAL TIME HAZARDOUS MATERIALS ARE THE PROPERTY OF THE CLIENT THE CLIENT IS <br /> RESPONSIBLE FOR PROPER DISPOSAL OF HAZARDOUS WASTES.CLIENTS NOT <br /> �' s' PICKING UP HAZARDOUS WASTES MAY BE ASSESSED AN APPROPRIATE FEE. <br />