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ne: <br />4 <br />Laboratories, Ine. <br />Chain of Custody Form <br />Sample <br />Matrix <br />lent: t Au�--" it! r-, <br />............. <br />Project #: <br />J P, M <br />Email Address: er, -�"j <br />Page o f <br />'Attn' Er"n ":-Ay-m"na <br />ProjectName- <br />L�ji� "CC -jcj� <br />Comments: <br />VW Global ID #: , A <br />Cit 0�4 <br />State, Zip:. av�' Sampler(s): 3,,,§ <br />,1 14 i il V- 4 1 'A 4 , rs, �1 -r I <br />�4. <br />ne: <br />4 <br />j <br />Sample <br />Matrix <br />Am iherT any fcstv 10th Wding ItM& IC55 ftirl <br />J P, M <br />Email Address: er, -�"j <br />or eTip) to 48 hours? <br />Yes ❑ No <br />Standard Turnaround 10 wor days <br />NVorkOrdcr#.- <br />S <br />1 <br />g, <br />915 <br />Other <br />Notes <br />fo ¢ i 09 q i tl� x <br />� -0 <br />I'YAkAv llv-ir- "'i ,� <br />111111171 "A 91 c 4 <br />, 11 l"l, , Nk'j <br />'" <br />L0 1 !!, <br />A 2- <br />• <br />E '525 <br />J — <br />I nclax- <br />4— <br />J <br />.. ......... . 9�mple Disposal <br />Same as above EDF Required? <br />Special Reporting <br />QC [j EDF Raw Date <br />E] Return to Client: Dispmol by lab <br />Iclient. <br />El 'krchivc: <br />Months— <br />Yes No I. Relinquished By <br />Date <br />Time <br />1. Received By Date Time <br />Address;tx <br />Lr -4 I _v <br />ad eA 2L <br />S -LLIL— Zip <br />city: 6- tate <br />Send Copy to State of <br />11 (EDT) <br />2. Relinquisbcd By Date Time <br />2.j�erviv�d By <br />Date <br />Time <br />Attn: r I C�— <br />El <br />3. :Relinquished 13y <br />Date, <br />Time <br />3. Received By <br />Date <br />"me <br />"me[ <br />1PO: <br />Yes No <br />I <br />BC Laboratories, Inc. - 4100 Atlas Ct. - Bakersfield, CA 93308 - 661.327.4911 - Fax: 661.327.1918 - www.ftclabs.com <br />I <br />