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ACCULAN <br /> '�.370 LA...010 fth-7,P-141—W CA 519SS <br /> P 0,BOR 809024,r*UrY -CA•9497541024 <br /> 7ai.,r,.n„Ira7jTsaazas IAx;t7Prji6SaC65 SAMPLE CHAIN Or,CUSTODY/WORK ORDER <br /> Cliont's Name 9 r1. <br /> Phone J <br /> A.dGress T1 rl� r:,c C'/..�.•�_ �� f�, � --, ---- , <br /> Ci;y,State.zip —[.Ale r —e eo <br /> Client's or Pepresantalive's Signature <br /> (sigrhatu+e auin:ixes the work and terms fisted below) ♦ j <br /> All samples remain she property-of the client who is responsible for disposal.A disposal fee may be imposed if client fails <br /> to pick up samples. <br /> PRCkI.NO. PROJFCT NAME <br /> SAMPLERS(S18Pey' /t N0 yep \6 �� R 11✓ REMARKS <br /> OFLA6 <br /> �� ^� I <br /> CON• .il USEONLY <br /> STA.NO. DATE Tji4 P{ a m STATiCN LOCATION TAiNERS1v� LAB Na <br /> l <br /> 7 <br /> ice: I l <br /> " 9erin0w DATE — <br /> i�r��6.LL - Ger+arF!Rsmula: � <br /> Relinquis :f 1 DATE TIME W: 1 ... � <br /> 76Y�S7rr �'4l/ Q4 L Lial l <br /> Re[si»A rsq�nwr, J <br /> Ihco7�e�J i "a <br /> p4hrQuah"by.rsipn,rw.j DATE TIME <br /> l <br /> I <br /> 1r 1 <br /> 1 <br />