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- <br /> i. __J .._..J ,....--,J _..r,_1.1 <br /> 5 <br /> CHAIN OF ^USTODY I ANALYSES REQUEST FORM 8'goa Q <br /> Project No. : G ! Field Logbook No. : Date; Serial No. <br /> Project Name:sry .51 ! �� �� �I Project Location: L N4 4300 <br /> 1 G� J G o-1 <br /> Sampler (Signature) : ANALYSES Samplers: <br /> SAMPLESA., �ti,. �Q `1Z <br /> • el-I e <br /> SAMPLE NO. DATE TIME LAB SAMPLE NO. <br /> OF— <br /> N0. SAMPLE REMARKS <br /> TAINERS TYPE Q <br /> z �5 CLIA- t S ► <br /> Q C . . <br /> ! S b <br /> z o� <br /> RELINQUISHED BY: DATE TIME RECEIVED BY:/ <br /> (Signature). / Z (Signature) �� DATE <br /> TIME <br /> 6 , <br /> RELINQUISHED BY: DATE TIME RECEIVED BY: DATE TIME 7 <br /> (Signature) (Signature) <br /> RELINQUISHED BY: DATE TIME RECEIVED BY: DATE TIME <br /> {Signature} <br /> (Signature) <br /> METHOD OF SHIPMENT: ! DATE TIME LAB COMMENTS: <br /> ~ I <br /> Sample Collector: LEVINE-FRICKE Analytical Labor tore <br /> 1900 Powell Street, 12fh Floor <br /> Emeryville,Ca 94608 <br /> (415)652.4500 As _SDC <br /> Shipping Copy {White} Lab Copy (Green) File 'ocy (Yellow) Field Copy (pink) FORM NO. 86/COC/ARF <br />