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Company Nae/Address. Billing Information: <br /> m Chain of Custody Page \ of2� <br /> Fulcrum Resources Env - Monrovia, CA Don Kellar/John Winkler Pres <br /> 415 W. Chestnut Ave. Chit ace Analytical® <br /> Mo Chestnut Ave. Monrovia, CA 91016 <br /> Monrroo via,CA 91016 <br /> i <br /> Report to. Email To: _ _ tzars ban" <br /> pa lao„� wle�.to gnzz <br /> Forest Kan forest@frenviro,mm;ian@frenviro.com O wWnamga umpk„,ma<Ivnui<mtoW <br /> el 1.0one—kn"'ledgment and u<eptanne of the <br /> Project Description: —City/State afbLK*,,s Gh Please Circle: 4 2 m »<e r.m,,,na cuanom rwmar. <br /> utps TPnfo.ea<eub..amr-h-heWtSOmard <br /> ehme p <br /> Collected: y PT MT CT ET CleO an S = <br /> Phone:805-338-8008 IClient Project# Lab Project# Z, o r, SDG# <br /> 15:�L-9165-6 FULRESMCA-FOREST ON : E u -.. <br /> c S $ d a = = E030 <br /> Collected by(print): Site/Facility ID# A P.O.# C Z Z on o <br /> f_0vv--' Kit,n N�1 -70-L E E L p Z �_ ei Q Acctnum:FULRESMCA <br /> Collected j re); Rush? (Lab MUST Be Notified) Quote# y y 0 m U i OE Template:T191696 <br /> ( <br /> Same Day Five Day CL m ,^y ? o C ¢ ao Prelogim.P861801 <br /> _Next Day _5 Day(Rod Only) Date Results Needed ~ OL .aa OV C) UD PM:546-Jared Starkey <br /> Immediately _Two Day _10 Day I Rad Only) No /— Q O .0 0 K 00 <br /> Packed on Ice N_ V _Three Day of Q Q O a .� O FJ > FB: <br /> V V 3 N Shipped Via: <br /> Sample lD Comp/Grab Matrix' Depth Date Time ntrs of p ,�.ra,k: Sample ppae only) <br /> --_— --- O t9 2 > v 3 3 3 <br /> SS to (, �I o 10 <br /> sBS'ts (, Ss S (o LI pSIS x 'A -0 <br /> 5 lS l -za G ss .-_0 <br /> 6WFt tD 0 4$ �yo�p <br /> - seZ IT ~ swryk IS vgoo y t <br /> 55-113VIV-'k. so 0CIta je Irf rloL, D <br /> S54rff'--N 04`40 4 hoLID <br /> G ss 9 014s 4 ( kC>I ) --G <br /> C,$ 3 <br /> "Matrix: Remarks: Sample Receipt h ck i,� - <br /> SS-Soil AIR-Air F-Filter pH Temp COC Seal Present/intact: NP Y COC Signed/Accurate: _N N <br /> GW-Groundwater B-Bioassay Bottles arrive intact: _N <br /> WW-tanking at Flow Other__ <br /> DW-Dfinkln Writer - --_ Correct bottles used: >� _N <br /> g /+ 1 Sufficient volume sent: N <br /> OT-Other Samples returned via: Tracking# 7 Q f X 0A 1 2 L�(,/ <br /> Ups FedElt gOUf12f v (✓ It Applicable <br /> VOA Zero Headspalceace: Y N <br /> ReImqush!ej_by,.(Sign re) Date: Time: Recei ed Is (Signal Trip Blank Received: Yes No Preservation correct/Checked; y/ N <br /> RAD Screen a0.5 mR/hr:-- Z _N <br /> 00 HCL/MeoH <br /> TBR _ <br /> R e— d b)(Signatu Date/ % Time: Received by:(Signature) Tempr3 B°ttles Rece'°e l: H preservation required by Login:DateJTime <br /> —� "'�� bry L /S _ _ .l-1.0 (V 6 <br /> Relinquished by:(Signature) Date: Time: Received at <br /> for lab by:(Signature) Date: ''t Time: <br /> ^/, Hold: Cpndill <br /> ait vcr V-- M.cj /11111 V"fW NCF /00 <br />