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Mr <br /> DARLAWFATOxM <br /> d,00Lakeville HighweY Petaluma,CA 94954 <br /> Mx 808024 Petaluma CA 94975 8024 <br /> one 17071 763 8245 Fax 1707)763-4065 SAMPLE CHAIN OF CUSTODY/WORK ORDER <br /> Client's Name / E Phon <br /> Address l HZ vv <br /> Clty,State,Zip ��t^ <br /> Client's or Representative's Signature <br /> (signature authorizes the work and terms li elow) <br /> All samples remain the prope f the client who Is responsible for disposal A disposal fee may be Imposed if client fails <br /> to pick up samples <br /> PROJ NQ �[P7RECT NAME <br /> SAMP79n"401 <br /> REMARKS <br /> NO <br /> OF LAB <br /> CON- \ USE ONLY <br /> STA NQ DATE TIME eL m STATION LOCATION TAINERS O LAB NQ <br /> 8 <br /> I <br /> r <br /> i <br /> t <br /> i <br /> i <br /> � 1 <br /> by( tare) DATE TIME Received by (Srgna ) Goner amarks <br /> �r /1 <br /> ul by-(Slgneture) DATE TIME Recehrad by (.S nature) /f 7/z LE �nO <br /> by(Signature) DATE TIME Rwehred by (Signature) ` <br /> DA Err-nxrn- I Act t+ndv <br />