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Columbia <br /> Analytical <br /> lob Courier Sample Receipt Record4Service S,rc <br /> Date 20 Ict 5— <br /> Companv Lam{ _4 � <br /> Project No <br /> Number of Containers Coolers Boxes _ Other <br /> Custodv Seal(s) Present YES NO Custody Seal(s) Added YES NO <br /> Containers Relinquished Bv: Signed Name <br /> Printed Name (.9 r,r <br /> Company <br /> Date and Time, <br /> Containers Received By (Couper): Signed Name <br /> Printed Name L <br /> Company G '211 f <br /> Date and Time <br /> 5� <br /> Containers Relinquished By (Courier):Signed Name Cr <br /> Printed Name C- � A C-� 1 ' l <br /> Company f 1 C - <br /> Date and Time `T <br /> Containers Received By (Lab): Signed Name <br /> Printed Name <br /> Company <br /> Date and Time40 <br /> Note Samples received via courser will be officially received and processed at CAS' Sample Recmvmg Office. <br /> 1921 Ringwood Avenue, San Jose, California 95131 <br /> Telephone: 408-437-2400 Fax: 408437-9356 <br /> covREMU,Doc 4nAs <br /> � r � <br /> 4 <br />