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CHAIN OF CUSTODY RECOFI&ND ANALYSIS REQUEST f JC4 f I Wf) CO CC //Y 6 C1 <br /> 5500 Boscell Common Fremont CA 94538 Tel 510 490-8571 Fax 510 490-8572 <br /> OWSIMEProtect Manager (ncorf) e ��-{�k� BIII to <br /> E N V I R O N M E N T A L Client Name O QS r e V o .uwd Company <br /> LABORATORIES, INC Address <br /> s Address _ <br /> City, State ZIP Sun c,, c City, State ZIP <br /> Phone 22Y 3 5- x,99/6 Phone <br /> Date 9 Fax Fax r, <br /> Page / of <br /> Laboratory Protect Name C A ,"AS P—6 —N o c, -7 3 If t V <br /> Lab Number F 0/ Protect Number 3 UU Elis$ -U <br /> Analysis Requested <br /> L <br /> m N a W (00,.� Y N <br /> yCd Q <br /> Cr <br /> Sample Identification Date Sampled Time Sampled Matrix J a. 4 Remarks <br /> M w-6 - Y� c c 5 M �F ot6 ! x 3 <br /> 7/ V9 !klo Gt/ FZ 0 3 <br /> ' - ?-A-5 4-3 L) w 3 s- '16 Y .3 <br /> (l 900 -17 <br /> 3 <br /> Initials Printed Name Signature Date <br /> 9 } S Total Containers <br /> M Y M'C`.�.�� y.it o�S� �1t2� �✓ Start Time Received Intact <br /> G�t)r �►�w;rA Stop Time Received Cold <br /> 7K Hours Custody Seals <br /> Client Sign-off <br /> White Copy -Admin/Lab Yellow - Mobile Lab Pink - Client <br />