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CHAIN OF CUSTODY REPORT �� BEN <br /> �� <br /> T <br /> Beacon Station No Sampler(Print Name) Date Form No <br /> ANALYSES �' L t ' + of <br /> Project No Sampler(Signature) r <br /> If _ <br /> Project Location Affiliation <br /> LD 0 <br /> o <br /> w = :r �! <br /> Sample NoJidentification Date Time Lab No m a- P"" z REMARKS <br /> t � tA <br /> Relinquished by (Signature/Affiliation) Date Time Received (Sign e/Affi cation Date Time <br /> l '+ , ,, , , o 1 <br /> Relinquished by (Signature/Affiliation) Date Time Receivep b ignai re/Affdi i n Date Time <br /> Relinquished by (Signature/Affiliation) Date Time Received by (Signature/Affiliation) Date Time <br /> Report To Bill to ULTRAMAR INC <br /> 525 West Third Street <br /> Hanford, CA 93230 1 ., <br /> Attention <br /> 17 <br /> . WHITE Return to Client with Report YELLOW Laboratory Copy PINK Originator Copy 3890031M i <br />