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4 <br /> ® DeMenno/Kerdoon Chain of Custody <br /> "Recycling For A C k aner Env;ronmen?` <br /> iaa 2000 North Alameda Street&Compton,CA 902222 ate � � � of- <br /> CA-DHS <br /> (310)537-7100 Fax:(310)639-2946 Page� <br /> GA-DHS ELAP Gertif'scate#2037 <br /> -- <br /> Client.- - Contact- Te P Fax <br /> _ ,- <br /> address: city State Zip ode: <br /> ............................ <br /> .. <br /> Project Name. Sampler(s) Signature: <br /> 'reject Manager: i approved <br /> Due Date Regular Rush GaysComments: <br /> Laky Hate Time No. of <br /> Sample Description ICS Collected Matrix Containers Analysis Requested <br /> x . <br /> Sample Conditions: Seal f.._ Intact F Broken None: Temperature Geld Room; Other <br /> _ _ _-_._._. _._ _ -- <br /> Relinquished by (Signature) Received by (Signature) DatelTime <br /> Relinquished by (signature) Received by (Signature} Date/Time /0,,- 12-11 /) <br /> _. ___._ <br /> Relinquished by (Signature)-- ... � _ Received by (Signature � .� ,° ate/Time <br /> _ _— <br /> SPIL INSTRUCTION <br /> y: P <br /> 0 . , 11 <br /> WHITE COPY–,-client PINK CO —courier <br />