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rt 3 - .-�§ `- t!^ 1,"` rte'• � �. !w� �.,.. ➢�� - � � <br /> 1 <br /> A"I V LAn <br /> •ed tete.eJ*XW*+7.r-skank,CA wu <br /> eae S0074,retak4n+,CA. 94073-1024 <br /> __ *�wwb..,trsrtzesax.s rRutmrixs4des SAMPLE CHAIN OF CUSTODY/WORK'IRDER <br /> Client's Name 1��+ _ oor <br /> Add:ass 93o& r.,.I <br /> r r <br /> - Gty.State,zip_ r r r. .. r4 ir — <br /> Clianl's or Representative's Signature <br /> 'signature authorizes the work and terms listed below) <br /> All samples remain the property of the client who is responsible for disposal.A disposal fee may be imposed it client!alts <br /> to pick up samples. <br /> PROJ.NQ PROJECTNAM <br /> SAMPLERS(' NO. \\�\ REMARKS <br /> OF L LABSTA.NQ DATE 1fIME g stz+lpr,hr LOCATION T JNNERS {4- t3-°�0 `4Q�: L� USP ONLY <br /> L `k LAB NO. <br /> S�3 qz7 1510 t ! k x <br /> .2Q•f) e <br /> SrI <br /> e- <br /> V <br /> y /'d C <br /> X <br /> 13-V zo.o <br /> � 1 � <br /> k k A k X I� <br /> -s SCS—l` k -'L <br /> _s f Jsoe kkrtix ,� <br /> - 204- (' 1 x X x X <br /> B ?so <br /> SO C f k Y Y x <br /> P"'^+ e�!>7rf5gnah+�1 DATE TARE Recened 6y:f5gneture <br /> _ 1 General fiem/arly: ^ <br /> Ralinquiahed .jSdgrm&") DATE TIME Received by:( WON) I✓ rX N�� � - <br /> !p <br /> > err+dA:fSr�relunr; DATE TIME Re avWvy:(Spnaru ) -.31�t ` U J f <br /> CLIENT COPY <br />