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L-] <br />71e � / ne�ero u <br />Tie Received <br />141 Z - <br />ME <br />by: (signature) ;Date/Time <br />Lillc,i f iz j <br />by:,'(: i %�ture)bate/Time <br />AAL qW11 01 <br />by: (signature) Date/Time <br />3— <br />�E <br />ils Intact' <br />Farm 1293 rev.11 <br />Sample Transportation Notice <br />RAVINE ROAD, SUITE B <br />Relinquishing signature on this document indicates that sample is being shipped in compliance with <br />180 BLUE <br />® <br />LTD. <br />all applicable local, State, Federal, national, and International laws, regulations and ordinances of <br />kind. Air Toxics Limited assumes no liability with respect to the collection, handling or shlpping <br />FOLSOM, CA 95630-4719 <br />FAX 985-1020 <br />wa <br />any <br />(916) 985-1000 (916) <br />CHAIN -OF -CUSTODY RECORD <br />of these samples. Relinquishing signature also indicates agreement to hold harmless, defend, <br />and indemnify Air Toxics Limited against any claim, demand, or action, of any kind, related to the <br />Page Of <br />collection, handling, or shipping of samples. D.O.T. Hotline (800) 467-4922 <br />Relinquished b igr <br />Project Manager 5 <br />Project Info: Turn Around ,�ab.use:orziy <br />Time: Pressurized by: '. <br />A _ <br />Collected by: (Print and Sign) ;4 <br />P.O. # _... <br />❑Normal Date: <br />_ <br />Company <br />Email Sb9sles-, (Z1clser�ceS'�c <br />❑Rush <br />Project # <br />j <br />Adds E -i�'` "" '%City j�l State Zip <br />pressurization'Gas: <br />Phone � - 64�'v Fax <br />' �9�'( '` Project Name fv0 `" ' _ <br />specify N2' �D <br />Date Time <br />Canister Pressure/Vacuum <br />Lab I.D. Field Sample I.D. (Location) <br />Can # of Collection of Collection Analyses Requested Initial Final Receiptgt�l <br />az <br />a - � ��� <br />9wR�? <br />_2 �� <br />.2r�� <br />71e � / ne�ero u <br />Tie Received <br />141 Z - <br />ME <br />by: (signature) ;Date/Time <br />Lillc,i f iz j <br />by:,'(: i %�ture)bate/Time <br />AAL qW11 01 <br />by: (signature) Date/Time <br />3— <br />�E <br />ils Intact' <br />Farm 1293 rev.11 <br />Relinquished b igr <br />�elinquishe by: (si <br />Relinquished b (Sibr <br />Lab Shipper <br />Use <br />Only <br />71e � / ne�ero u <br />Tie Received <br />141 Z - <br />ME <br />by: (signature) ;Date/Time <br />Lillc,i f iz j <br />by:,'(: i %�ture)bate/Time <br />AAL qW11 01 <br />by: (signature) Date/Time <br />3— <br />�E <br />ils Intact' <br />Farm 1293 rev.11 <br />