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amp a cans atlo ticM MIM = M =11M <br /> IR TOXICS LTD. P g PP p �$� BLUE RAVINEe- 1 <br /> UITE B <br /> Relinquishing signature on this ent indicates that sample is being shipped in compliance FOLSOM, CA 9563 <br /> with ail applicable local State, rederal national and international laws, regulations and (916)985-1000 FAX (916)985-1020 <br /> CaP <br /> N ENVIRONMENTAL ANALYTICAL LABORATORY ordinances of any kind Air Toxics Limned assumes no liability with respect to the collection, <br /> handling or shipping of these samples Relinquishing signature also indicates agreement to hold <br /> CHAIN-OF-CUSTODY RECORD harmless, defend, and indemnify Air Toxics Limited against apy claim, demand, or action of any <br /> kind, related to the collection,handling,or shipping of sampl�s` D 0 T Hotline(800)467-4922 <br /> _ Page of <br /> Contact Person pro ect info <br /> Company ,! j , Turn Around Time: <br /> PO_ f � � <br /> ormalAddress ��-State Q4Zip ?c Project# f MV <br /> y 'r <br /> Phone / ` - { D Rush <br /> FAX ` c= r ._-- _ Project Name Specify <br /> Collected By signature _ _ -- <br /> I <br /> ,r Lab _ <br /> ID <br /> Field Sample I D Date & Time Analyses Requested Canister Pressure 1 Vacuum <br /> _ Initial Final Receipt <br /> _.,_.....-__ <br /> 0 n � <br /> r <br /> s <br /> Relinquished By (8iTgature),Date/time Received by (Signature) Dateftime - <br /> Notes <br /> Relrn ursh d 8y (signature) Date/Time Redeived By (Signature) DatelTrme <br /> �c 1 <br /> Relinquished By (Signature) Dale/Time /deceived By (Signatufe) `DalefTlme y <br /> Shipper Name Air Bill# Opened By_ Temp (°C) Condition Custody Seals Intact? <br /> Lab , , �, Y Work Order 4 <br /> Use = } r' - ` 't it --- Yes No ne <br /> Only � _ r ^-�- � None <br /> Form 1293 rev 09 <br />