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C *N CF CLISi0DY RE .;D <br /> SAMPLER (signature): <br /> A,00iied Geo ,7,-e.,77,7 <br /> 4191-E Power Inn Ro2c.Sacramento. CA95826 (9161 452-2901 <br /> Phone: • Fremont •Costa Mesa •Sacramento <br /> LABORATORY: SHIPPING INFORMATION : <br /> Shipper <br /> Address <br /> Date Shioaad <br /> TURNAROUND TIME: Service Used <br /> Attention: Airbill No. Cooler No. <br /> Phone No. r <br /> Relinquisnea by: (signstureel I Received by.(signatures) I Date I Time <br /> I I I <br /> IRecaivea for laporatory by'. I I <br /> LASCRATORY SHOULD SIGN UPON RECEIPT AND RETURN A COPY OF THIS F-ORM WITH THE <br /> LASCRATCRY RESULTS <br /> Sample Site Date Analyses Sample,Condition <br /> No. Identification Sampled Requested Upon Receipt <br /> EXAMPLE OF <br /> CHAIN OF CUSTODY RECORD <br />