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s� <br /> Ah <br /> �!LC a oratories, Inc. Chain of C stody Form .11rCTOUorziD <br /> Repan To <br /> r <br /> Client. r L• Pro ect#• `ltakw( � " ' " • 46003 page of <br /> Attn u F4.-�,.rn Project Name C � P�'��P� Comments: <br /> iStreetAddress- 2-1 T4_►^s,•!o Je,� Pro ect Code It) l t �' <br /> 14 ��cr to � t �� ��t� ��It;, <br /> City,State Zi :1,w _G `t Sam ler s ,y � N`�� tyt -ol 1p1 41, 1 <br /> Phon4MJ 15 r-7y'i� F34111 713--ell( btdCal MAT QW1IIIr ho as 711 ntc In t1 <br /> Email Address.Z' —1_(k�. f•�"CSv o+�r. 1'Tt i t1 Sample Matrix a Are there an nreequar to 49 holding gshmes less[hen <br /> rs <br /> Submittal#• [ f,! 3 3 ,o ❑ vas ❑ No <br /> Sample Description Date Timeg w *Standard Turnaround=15 work days <br /> Sampled Sarnpl&� A 0 3 other Notes <br /> 1AW 6 050Yy �e I Y 3 Un <br /> —4 MW-10 0130 <br /> -5 W (06o <br /> (49 A4 V-7 10Iq <br /> —�? /rw-3 cap <br /> Aw- a.. L v3 <br /> AV-4 2- <br /> � <br /> 121'saine 8S above <br /> Report Drinking Sample Disposal Special Reporting <br /> Waters on State Forms ❑ Return to Client ❑ Disposal by lab ❑ Archive Months________ ❑ QC ❑ WIP ❑ Raw Data <br /> Client ❑Yes ❑No 1 Relinquished By Date Time 1 Receiveed�By Date Rinne} <br /> Address, ————— 06,-2_71�u r `t i`+5 -e, r- CPSa 3 {-1 <br /> Send Cbpy to State of Re u Date Time 2 e lived By Date Time <br /> City State Zip CA, <br /> Z -us 6oS <br /> Attn' ❑Yes ❑No ingwLed Dat Time a eived By Date lime <br /> Po# <br /> BC Laboratories,Inc -4100 Atlas Ct -Bakersfield, CA 93308 661327 4911-Fax 6 1 3271918--www c <br /> !., <br /> r <br />