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f � <br /> 4 <br /> CHAIN - OF - CUSTODY RECORD <br /> SAMPLER (Signature) <br /> ' <br /> 3"J�k��= <br /> Date Sampled 4- `S fa g Date Shipped Carrier <br /> ' SHIP TO SEND RESULTS To- <br /> Mr. Chih-San Ho Mr Philip L Chang <br /> ' Eureka Laboratories, Inc. Balbi 8 Chang Associates <br /> 3401 La Grande Boulevard 151 Link Road, Suite A <br /> Sacramento, California 95823 CordeLia, California 94585 <br /> ' (916) 428 1193 (707) 864 2020 <br /> PROJECT NAME �o _ PROJ N07(Signattuir <br /> LZ-OS — <br /> �Oinquis d by (Signature) cieved b ) D e Time <br /> Relinquished b (Signature)g natur <br /> e) Recieved by: (signature) Date Time <br /> ' ANALYSIS REQUESTED <br /> Sample ID Sample Date/Time Analysis Requested Sampled Condition <br /> ' Number Description Sampled Upon Reeiept <br /> Special Instructions/Comments. <br />