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Laboratories, Inc. <br />Chain of Custody Form <br />PLEAW CX)MPI.r-,Tr..: <br />B. CT, 0U IT, F. TD: <br />Rep�"of <br />Client: Ne rs, f A�50644ffS �L,74C <br />Pro #: <br />Pae <br />Attn: As ,,Jq r <br />Pirpiect Name*VU AwAlx <br />Comments: <br />+R.. <br />Street Address: IWO 5.�Ly- 74 ,U, 0,,jL,,>, Pj <br />Global 11D #: <br />vic. r— <br />Cit V StateZip5-AzkA0 03d4 <br />, r <br />- <br />_sampler(s):Q1jj";'Ad&n- <br />Phone: 63 6-5'3 I -D) I Fax: 43a <br />Pkase FOP)�r�0nUm /I <br />Email Address: j <br />Sang e Matrix <br />tests with hold ng times less than <br />Are them any or equal to 48 hours? <br />Work Order #: <br />-1 Yes El N. <br />E <br />3 <br />x Standard Turnaround = 10 work days <br />0 <br />0 3 Other <br />Notes <br />C YA'al ka e I 1 4 <br />91) 109 073'9 )C <br />4 Well* 4 D6e4<at,e_ <br />9 <br />,13 IP&P Well"Ll— <br />C17. <br />Y <br />C weft 1 <br />07SS <br />X <br />CYA*Z. IAIel 1 <br />1,6 <br />0 UL <br />X <br />I 1A <br />16 r -Be 1",rd,&, <br />7 nJdvr <br />/V/Y( <br />CAK §11 <br />LIB im <br />Sample Disposal <br />❑ Same as above Report Drinking <br />Waters on State Form? F] Return to Client Disposal by lab El Archive: Months— <br />Spetial Reporting <br />❑oc F] EDF [] Raw Data <br />Client: r k/J r Ld <br />1. Relinquishe Date <br />Yes �No he <br />Time A.1"ved By <br />Dat Time <br />W7, loki <br />Address: 9165 A"ShA PIA'- <br />- — — — — — - <br />106 <br />City: AkAfgco, state CA zip <br />Send Copy to State of <br />CA? <br />2. RAIA(luish Soy <br />Date <br />w <br />Time <br />Received By <br />Dae <br />_j <br />Time <br />Attn..CA 65-6,u, 6eirb" f <br />XYes 0 No <br />3 Relinquished By Date Time <br />A— <br />3. Received <br />Date <br />Time <br />. .............. ............. <br />k-1 -a <br />BC 1aboratories, Inc. - 4100 Atlas Ct. - Bakersfield, CA 93308 - 661.327.4911 - Fax: 661.3Z/.1918 - WWW,DCIaDs.com <br />= M M M = M M M = = M M M M � M M = M <br />