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• CHAIN OF CUSTODY REC,*AND ANALYSIS REQUEST • <br /> 5500 Boscell Common Fremont CA <br /> ,*AND <br /> 510 490-8571 Fax. 510 490-8572 <br /> ONS/TE Project Manager Bill to: <br /> ENVIRONMENTAL Client Name: Company: <br /> LABORATORI ES, I NC. Address: Y11 A44� cam/ 7 Address: <br /> City, State ZIP " C City, State ZIP <br /> Phone: - Z Phone: <br /> Date: Zd6 Fax: 779 Fax: <br /> Page: of <br /> Laboratory: Project Name: P.O. No.: <br /> Lab Number: jProject Number: <br /> Analysis Requested <br /> D � � <br /> m N p <br /> n Q K > p X �' V U <br /> c m <br /> Sample Identification Dale Sampled Time Sampled Matri■ in H m a a z Remarks <br /> u- I-1 3-r 9: ID'os P 3&LV3-0I <br /> V- Jr- 3- I '10 I 1 '07- <br /> 3 -02 -o <br /> u-Baz- o -rc : Yr <br /> SII-L3a3' 5 3- 3: oo Gaa _0-7 <br /> 60 -8,9D- 0 3-6 3:3a -6 <br /> ials: Printed Namq: tur Date: —/ (/U Total Containers: <br /> Start Time: Received Intact: <br /> IP lUE_ Stop Time: 3.30 Received Cold: <br /> Hours: Custody Seals: <br /> Client Sign-off: <br /> White Copy -Admin/Lab Yellow- Mobile Lab Pink-Client <br />