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CHAIN OF CUSTODY RECORD <br /> Opp APPL, Inc. Phone: (559) 275 2175 <br /> 4203 W. Swift <br /> Fresno, CA 93722 Fax: (559) 275-4422 c.o No 17528 <br /> Report to: <br /> PLEASE PRINT Invoice to: PLEASE PRINT <br /> Company Name Ckt;A 2 hal Phone:5/0-�S/— �'h� Company Name C���k�� �C� 7— Phone: <br /> Address / cS S G r / Address .t!DCS <br /> SMS j C/� 9�L1 Fax: 116 —���— `LU �(,� Fax: <br /> yam, <br /> Attn: ✓ z� SGvY Attn: <br /> Pr . t�u beer Sampler(Print) Analysis Requested/Method Number Date Shipped: <br /> Carrier: <br /> Purchase Order Number Sampl Signature) ti . 3 Waybill No.: <br /> Comments: <br /> I <br /> Sample Identification Location Date Time Matrix Number of <br /> Collected Collected Containers <br /> MCA re eve pay, <br /> S' �-- 50 N_ 4v <br /> Shuttle Temperature: Turnaround Requested: MUST CHECK ONE � Sample Disposal: <br /> ❑ Standard(2-3 week) One wee 24-48 hour [D Return to client E] Disposal by Lab(30•dey retention) <br /> Reli quished by sampler: Date Time Recei a by: f b ed by: Date Time Received by: <br /> Relinquished by: Date Time Recel ed b Relinquished by: Date Time eived a y: <br /> 5 a cgc <br /> White:Return to client with report Yellow:Laboratory Copy Pink:Sampler <br />