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i! Ml MM MM Mr• ittf� <br /> � CHAIN OF CUSTODY RECORD 1145-A DAM <br /> —ofY NUMBER <br /> J <br /> _VM <br /> n"InduWlal Ave,West S*=ffW %CA.95691-135(916)3721393 /012 y - f4139 <br /> A COMM9 Com an 7440 Lincoln Way,Garden Grove,CA.RMI 1432(714)8988776 LAB NUMBER <br /> p Y ❑18561 Emd Gale Ave.City of Industry.CA.91740.1921(8le)965'1608 2 of <br /> ❑Mobile Labe,1(a66)ENSEW-9 <br /> CLIENTPROJECT MANAGER ANALYSES <br /> S' co�2 1/c 11,42v <br /> +yy 2 fy� TELEPHONE NUMBER(AREA 1 <br /> ADDRE S j 0, <br /> CITY STATE ZIP CODE SITE CONTACT <br /> rvip� CA-L95 816, �' ` <br /> PROJECT NAMES �,` TELEPHONE NUMBER(AREA CODE) P�4� �Q�` �� L, <br /> Nov 2- -co/ of r [,�- 4 <br /> CONTRACTIPURCHASE ORDEWOUQTE NO <br /> LABISAMPLE SAMPLE TYPE NO,OF r �Q� Sample Condltionl <br /> pENTIFICATION DATE TIME - REMARKS <br /> SAMPLE NODI NUMBER uo AIR TAMIUIS <br /> 2 <br /> 10 !sl x k '� x x <br /> - Mw- Z ray X X <br /> 02-q9 —Mui— o )4 x x X <br /> Io l X x x X <br /> p g -~-; I X ro x x x <br />� X X <br /> 2,l x x <br /> 0 X x X X <br /> DO THE SAMPLE(S)POSE ANY POTENTIA.HAZARD(S)7 IF YES,PLEASE EXPLAIN00 <br /> 79EC.v�MFOR <br /> TORE) RELINQUISHED BY(SIGNATURE) lsH BY{SI NATUR DATE TIME The delivery of samples and the signature on this chain of ' <br /> custody form constitutes authonzatwn to perform the analy- <br /> IGNATURE) DATE TIME RECEIVED BY(SIGNATURE) DATE TIME ses specified above under the Ens�eco'f erms and Cionditions, <br /> uniess acontract or purchase order has been executed andis sited above <br /> LABORATORY BY DATE TI TAMPLE DESPOSMON: <br /> - RECEIVED aZy 74 / =/S+ ACCENTED �Qz�9tI / •'/5 1 Storage time requested days <br /> METHOD OF SHIPMENT (Samples will be stored for thirty(30)days without additional <br /> charge, thereafter storage charges will be billed at the pub- <br /> lished rates) <br /> SPECIAL INSTRUCTIONS 2 Sample to be returned to client. Q Yes❑No(Ertszew will <br /> dispose of unreturned samples for a charge of$15 00 Dis- <br /> posal well be by incineration wherever posslble,otherwise,as <br /> appropnate, ac cordln to legal r uirements) <br /> A <br /> DISTRIBUTION WHITE-with Report,CANARY-To ENSECO.PINK-To Coutler,GOLDENROD-To Sample C011W <br />