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TestAmen'R'caReference <br /> TESTAMERICA Pleasanton Chain of Custody o <br /> 1220 Quarry Lane • Pleasanton CA 94566-4756 N <br /> T_t OER Ire NIM VAl- 'TESTING Phone: (925)484-1919 • Fax: (925)600-3002 Date y - Page_._ L of r n <br /> RequestReport To Analysis <br /> Attn: U? oK E o <br /> LQ 1 r aqoZw�mm y ❑m rnm wndm.�dQI x [D J V c❑ <br /> LW G e W m F FOZ <br /> a <br /> Address:Jgp ❑❑ va� <br /> C11 <br /> El <br /> un <br /> o 00d <br /> m <br /> w <br /> CL <br /> C) 00 <br /> Email: 'F 09 <br /> ❑ O'Dw z C ° ❑❑ ❑❑ ❑❑ o <br /> Bill To. Sm led m U o ❑ 0 Z) <br /> 00 <br /> D- <br /> a) LU <br /> mm ❑ <br /> aod W gU) 13.� <br /> Attn:�tCGI Phone:L� Om gW O n <br /> —OZO a a aVn <br /> r 0 U4U Zdd 3d <br /> 7 iV <br /> :E [313 ❑w N N <br /> ❑ acoN <br /> i <br /> Z <br /> t I <br /> 11aa <br /> ,y <br /> nx <br /> If <br /> 720-64484 Chain of Custody <br /> Sample Receipt 1)Re lin fished b 2)Relinquished by: 3)Relinquished by: <br /> Project Namel#. -Fof Containers: 114. 5 <br /> ; <br /> �� aYl� SlKtAZU <br /> Time Signature Time Signature Time <br /> Head Space: me �� 4- e Printed Name Date Printed Name Date <br /> PO#: Temp: d Printed Name Da e <br /> -l C-Fjt <br /> Credit Card <br /> YIN: if yes,please call with payment information ASAP Company Company Company <br /> T 10 5 4 3 2 1 Other: 1 7;— <br /> SynAture <br /> by: 2)Received by: 3)Received by: <br /> TDay Day Day Day Day Day <br /> /y (Tim r Signature Time Signature Time <br /> Report: ❑Routine O Level 3 ❑Level 4 ' EDD ❑EDF J, w(l �1� I�, <br /> Special Instructions/Comments: O Global ID Printed lame � Date Printed Name Date Printed Name Date <br /> Sea 7em's and CondWom on me se Co�m{�p{{a�.ny' Company Company <br /> Rev.1012012 <br />