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CHAIN OF CUSTODY 1 ANALYSES REQUEST FORM <br /> Project No f f 5-1 1 0 C) Project LocationL <br /> ����•hj,1 � Date 1 r 1!/cl 7 Serial No <br /> Project Name L • Ge i k Field Logbook No 11 W 1402 <br /> Sampler(Signature) 9 ANALYSES <br /> Samplers 3 �i <br /> SAMPLES <br /> f 014) <br /> SAMPLE NO DATE TIME LAB NOSAMPLEF <br /> CON SAMPLE REMARKS <br /> _ TAWERS TYPE V <br /> ci4Aiw- LP <br /> LO <br /> k Al <br /> nh'V- 3 0017 11 z o - --- - - - �•� 5 fb <br /> LNMw- Z, 11/11/-17 <br /> re -1110 1/0/f <br /> i <br /> RELINQUISHED BYRECEIVi"D 9Y D <br /> DATE TIME <br /> E , TIME <br /> (Signature) - J/�/f�/� -�`}, <br /> (Signature) <br /> RELINQUISHED BY DAT TIME <br /> RECEIVED BY <br /> {Signature} (Signature) r Q� �_ DATE TIME <br /> RELINQUISHED B �� <br /> DATE _ <br /> TIME RECEIVED BY <br /> (Signature} DATE <br /> (Signature) TIME <br /> METHOD OF SHIPMENT DATE TIME LAB COMMENTS <br /> kl-p/ <br /> Sample Collector LEVINE•FRICKE•RECON Analytical Labo ory <br /> 1900 Powell Street, 12th Floor <br /> Emeryville, California 94608-1827h-7 <br /> (510)652-4500 V ��rn� <br /> Shipping Co Ile <br /> PP g PY(While) Lab Copy(Yellow) File copy(Pink) Field Copy{Goldenrod} <br /> COC COR 1015961M <br />