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Ultramar Inco 0 D�1' BEACON <br /> CHAIN OF CUSTODY REPORT <br />� lMr�xMr <br /> I <br /> Beacon Station No Sampler(Print Name) Date Form No <br /> ANALYSES -:r-22-9'7 1 3 of <br /> Protect No Sampler(Signature) Of <br /> -'6 3-`0 a _ T _ <br /> Project Location Affdia bn <br /> xUJ <br /> °' o <br /> Sample NoAdentification Date Time Lab No m z REMARKS <br /> Vv- .5-17-27 3y-a ~--p7 <br /> W 4-L7 ---/, <br /> Relinquished by (Signature/Affiliation) Date Time Received by (Signature/Affiliation) Date Time <br /> n <br /> Relinquished by (Signature/Affiliation) Date Time Received by (Signature/Affiliation) Date Time <br /> Relinquished by (Signature/Affiliation) Date Time eived by (Signature/Affiliation) Date Time <br /> Report To Bill ULTRAWAA INC <br /> 525 West Third Street <br /> Hanford, CA 93230 <br /> Attention �:�.', <br /> WV Return to Client with Report YELLOW Laboratory Co PINK Ongmator Copy 4F <br />