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Xm = = = = = Is = = <br /> eftrum Analytical Laboratories, Inc. Centrum Job # <br /> 290 TENNESSEE STREET (909)798 9336•(800)798-9336 Cham of Custody R Ord / <br /> REDLANDS,CA 92373 FAX(909)793 1559 <br /> Page of <br /> -1 Analyses Rec uested <br /> Protect No Protect Name E <br /> r0 , 1 m o „ Turn-around time <br /> 6-251 o s <br /> Protect Manager [y Phone I Fax M ❑ 24 Hr RUSH' <br /> 7 S—I{ o a _ ❑ 48 Hr RUSH' <br /> Q.DIs o ❑ Normal TAT;;Client Name <br /> ILL <br /> (Company) {azo VJ, AVE. qL1 S sno rw <br /> a! <br /> w eddronordmroasap* <br /> Centrum ID Sample ID Date Time Sample Containers a° Z _ Remarks/ <br /> Sete location <br /> (Lah use drYyl (As 0snoWd appear on report) sampled sampled matrix #and type � � � W t' � �, Special Instructions <br /> [ry pn 1 pm apo v N r3. LL <br /> VOAr <br /> 13 00 }C <br /> '� ►�1,.1 -�`f Imo- s � t 3•� � j� `}-�, <br /> R uish d by (Sa �s7tur` Date Time Relinquished by Date Time <br /> �' _ZO To be completed by laboratofy personnel Sample Disposal <br /> 17 <br /> Recerved y D e Time Received by Date Ti ma Samples chilled? Yas ❑No <br /> Custody seals?C❑Yes No <br /> ❑ Client will pick up <br /> Relinquished by Date Time ""fit <br /> The delivery of samples and the signature on this chain of custody form A l sample containers intact? as 13No [3Return to client <br /> constitutes authorization to perform the analyses specified above under Receive Labor tory by Date Time ❑Courier [P�dQand carried <br /> the Terms and Conditions set forth on the back hereof v ❑ Lab disposal fee$5 <br /> ,� l� �� `1 <br /> Laboratory Notes Sample Locator No <br /> VD's - <br /> White Copy Original(Accompanies Samples) Yellow Copy Centrum Files Pink Copy Client Copy <br />