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ABLic> Laboratories, Inc. Chain of Custody Form <br />Analysis Requei <br />tea,•.`. T,.. .�.._ <br />Y <br />Attn: 0w ik i-�+telt' Project Name: INM <br />C- <br />,CAomme s 2 <br />�- = dJQt`tlrtl'7�� W <br />Street Address: n a5, Global ID #: <br />d 3�0d Sampler(s): <br />/t,D <br />pts? c <br />Ci State Zi , 91d <br />Phone 3 j `7 Fax Mq <br />• <br />Email Address: c en,c <br />Sample Matrix Are there any tesstts witualh holdinghoo 48 times less than <br />Work Order #: <br />@ ❑Yes No <br />SampleHe <br />" a <br />Time® <br />— a 9 7 3 Standard Turnaround = 10 workdays <br />Sampled <br />Sampled � <br />o� �..� ik <br />cn vt A C7 3 Other Notes <br />� <br />l.. 0 111 o <br />1004 <br />� 1 <br />Q 41 <br />855 <br />�WcQi� C <br />OR.Ak� <br />Us <br />-7 <br />' <br />----------- <br />CFl <br />----.� <br />r. <br />❑ Same as above <br />EDF Required? <br />Global ID <br />System # <br />(Needed For EDF) <br />(Needed ror EDT) <br />riime <br />Received Dae Time <br />Client: LO�l�l <br />El Yes IG O <br />1 aqui a B� Dat%A H <br />�l <br />1. <br />Address: utSfa <br />— — — — <br />— <br />R.Y71` <br />/ to <br />n ./1� CA n <br />City: ` '�`�' State C! -t Zi <br />Send Copy to State <br />of <br />Z• elinquished By Date <br />Time <br />Rece' y Date Time <br />J I <br />At n- CA t A3. <br />CA, (EDT) <br />❑ No <br />�; -1 1 <br />k#AKT\)M <br />3. Relinquished By Date <br />Time <br />3. Received By <br />Date <br />Time <br />PO#: <br />BC Laboratories, Inc. - 4100 Atlas Ct. - Bakersfield, CA 93308 - 661.327.4911. - Fax: 661.327.1918 - wNvw.bclabs.com <br />I <br />