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C�'A.'N 4F CUSTODY RECO ;D <br /> Pj II IPLSR (signature): _ <br /> Applied G�oSVs:ems <br /> 4191-E Power Inn Roaa.Sacramento.CA 95826 (915)452-2901 <br /> Phone: •Fremont •Costa Mesa •Sacramento <br /> LABORATORY: SHIPPING INFORMATION: <br /> Shipper <br /> Address <br /> Date Shipped <br /> TURNAROUND TIME: . Service Used <br /> Attention: Airbill No. Cooler No. <br /> t Phone No. <br /> Relinquished by-(signatures) Received by'(signatures) � Date Time <br /> i <br /> I <br /> iReceived for laooratary by. <br /> LABORATORY SHOULD SIGN UPON RECEIPT AND RETURN A COPY OF THIS FORM WITH THE <br /> LABORATORY RESULTS <br /> Sample Site Date Analyses Sample Condition <br /> No. Identification Sampled R®Cuested Upon Receit)t <br /> P_5 <br /> rl.�iPLE OF <br /> CHA:Z OF CUSTODY RECORD <br />