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CHAIN OF CUSTOSECORD <br /> On APPL, Inc. Phone: (559) 275 2175 <br /> 4203 W. Swift <br /> Fresno, CA 93722 Fax: (559) 275-4422 <br /> C.O.C. N° 17528 <br /> Report to: PLEASE PRINT Invoice to: PLEASE PRINT <br /> Company Name Clyd2M //k l l Phone:-/0-,Ul- 0-7 Company Name C�o21 tl/�l//( ��'f1 Phone: <br /> Address ! S S �1�..� � Address <br /> 4 5;, Fax: S/n —���— 2v �� Fax: <br /> Attn: "✓lie Sa.Y ti.eay Attn: AIV ��21 <br /> Pr ' t�u mbeer Sampler(Print) Analysis Requested/Method Number Date Shipped: <br /> 0OD rn Carrier: <br /> Purchase Order Number Sampl Signature) 3 Waybill No.: <br /> ' e •o <br /> Comments: <br /> t <br /> Sample Identification Location Date Time Matrix Number of �� tJ <br /> Collected Collected Containers <br /> 77V �� l oa « ( re�vP,yl D►zL <br /> kjo <br /> sir- 50 n/_ ,2 v a •` /S v l <br /> Shuttle Temperature: Turnaround Requested: MUST CHECK ONE Sample Disposal: <br /> ❑ Standard(2-3 week) I ET One wee 24-48 hour ❑ Return to client ❑ Disposal by Lab(w-day retention) <br /> Reli quished by sampler: Date Time Recei a by: ( b ed by: Date Time Received by: <br /> Relinquished by: Date Time Recel ed'b . Relinquished by: Date Time ceive a y: <br /> White: Return to client with report Yellow:Laboratory Copy Pink:Sampler <br />