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Laboratories, Inc. Chain of Custody Form <br /> Environmental Testing Laboratory Since 1949 <br /> Report To: <br /> Client: f �( t h550t�� Project#: <br /> ' -e s <br /> Ann: Project Name: C C O.C. <br /> Street Address: Oj j Global ID#: Comments: <br /> i� Sampler{s): =1 A910'.A I��Gt It3 �✓ <br /> City,State,Zip:1 �590 ko a tA 10 <br /> Telephone: O, FQa 2X Iva <br /> �l , <br /> Are there any es w(th ding <br /> LEmail �CL Ci Sample Matrix times fess thafl 01 equal tD 49 <br /> Yhours? <br /> fkOrdef#:� 3 Yes NO <br /> c w [� <br /> Date .?; <br /> Sample Description Samf '• 0 fn V5 D 47 3: O F-- Notes <br /> 114P I <br /> -' doe✓ x �" I -�g- t tI ID <br /> �r'� <br /> 2— ✓ �aJCe:�' � <br /> -- � C <br /> 1 t1 e- <br /> -- � Z Ito <br /> Required? Sample Disposal Special Reporting <br /> ❑ Same as Above EDF Re q <br /> ❑Return to Client Disposal by lab ❑Archive Months- ❑QC ❑EDF E)Raw Data <br /> Client: 0 Yes ❑ No 1.Relinquy: Date Time 1.Received b .' Date: Time: . <br /> Address: --------------------------- {�'{`� `315 t!-ii )1-;1 -- <br /> City: State: Zip: Send Copy to State of CA? 2.Relinquish By: ate Time 2 by: e:4 <br /> Time: <br /> Attn: wue E4/yes ❑ No 3.Relinquish by: Date Time 3.Received by: Date: <br /> PO#: I I I <br /> kk <br /> BC Laboratories, Inc. 4100 Atlas Court Bakersfield,Ca.93308 Tel:800.878.4911 Fax:661.327.4911 Page 1 -of L <br /> ✓tr�iti�� <br />