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s r r r r r r � �■r r� � r � rr r4F �■ <br /> KF fJl4LUY/JLNKS CONSUL I AN I S 2G _ <br /> L� aNew Syne Rd 1176 eskeupeld CA9330B � 1 <br /> 61 BO Ned Road 1300 Reno NV 89602 <br /> SAMPLE CHAIN-OF-CUSTODY ANAL PSIS REQUEST a 63o south 33e,h s7 Pedant Way WA Bgoo1 ❑3336 B,edah—Rd 1140 Sac,wnante CA 96827 <br /> 0 17 3 10 Rad Nr11 Are 4`220 IrY,ne CA 92714 O 303 Second Sl San Fr <br /> 4107 <br /> ❑2101 East 6syslxne Rd 0200 Pale Aho CA 04303 +haat+ CA 8 <br /> ❑10001id1 Ad /200 Verdv CA 9300033 <br /> POSSIBLE HAZARDS (� )q. 151 <br /> Date 7 �� l� �� / I`76 < ser ANALYSES REQUESTED <br /> p _ Repart To .)� � �1� <br /> S f ` Lab Destination <br /> / <br /> Source of Samples �� .11 Company �l t"`u Cr `r""^4 �/ <br /> 5'J Address -I I-A) Vic aI ,(fit <br /> Sampler Meme ► "i/ 1� Address (�L r r <br /> Phone Coc <br /> q + (/ C p Phone ` S r(a C tj G C <br /> Pro)eci No 1 b d�� _dU Phone I S Z t� z S V ej a M u <br /> L, -C -l Carner/Wey Bill No <br /> LU tn <br /> to aN <br /> R <br /> ECTION 121 13) (4) Turn = j Z X CJLab fD No 41 <br /> ClienTarte Type Depth COrrffmnt/Coridltions <br /> Corrlp. Pres around > T (Contelrler type,contmner rturrl6er,etc x.55 <br /> y <br /> 1 5 1 <br /> Ill Write only one sample number In each space <br /> (2) Specify type of samplelsl Water IW),Solid IS) or indicate type <br /> 131 Mark each sample which should be eomposited In Laboratory me folbws Race an'A'In box for each sample that should be eomposited into one sample use sequential letter for additional groups <br /> Id) Preservation of sample <br /> 151 Write each analyses requested across lop Place an'X'in appropriate column to lndicate typo of analysis needed for each sample <br /> SAMPLE RELINQUISHEo BY <br /> f7rrt NameC-a� p Data '11ISAMPLE RECEIVED BY <br /> t1i,t N.m. S,pnatl„ <br /> C-ro•n1r oaoa Time <br /> FN , 11=A ' <br /> 7M78CIC1111 7 Fail <br /> 000lfe6 as <br />