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CHAIN OF CUSTODY RECORD AND ANALYSIS REQUEST <br /> N <br /> 55DO Boscell Common Fremont, CA 94538 Tel. 510 490-8571 Fax.(510)490-8572 <br /> Project 1�lanager. t L[_ (,�,, Bill to: <br /> O��'ME <br /> E N V I R O N MENTAL Client Mame: Company: <br /> LAB ORATOR I ES, INC. Address: Address: <br /> a <br /> City, State ZIP City, State ZIP <br /> Phone: Phone: <br /> Date: Fax: <br /> Page: / of-2 <br /> Laboratory: -S'I Project Name: P.O. No.- <br /> Lab Number: br?�R Project Number. �7-a2 <br /> Analysis Requested <br /> Z M 4A <br /> 0 5 <br /> oj$ <br /> O °Y 6 !Y > p o <br /> u X <br /> W Sample IdLU <br /> -ntificalion Date Sa pled Time Sampled lolatrx a~i F d z Remarks <br /> Q 1-- 10 V W ;t fl Lba3j-l5 <br /> I--2p a1z -t� <br /> 2---LD IZ-00 -{ <br /> r-, <br /> LOCSD <br /> CP <br /> N <br /> LO <br /> Ln <br /> �►1- r� r'� �7 <br /> Initials: Painted Game: A Signature: Date: Total Containers: <br /> m Y �`4�C � a v's Start Time: Received Intact: <br /> CNm <br /> Stop Time: Received Cold. <br /> CP <br /> Hours: Custody Seals: <br /> m Client Sign-off: <br /> White Copy -Admin/Lab Yellow - Mobile Lab Pink-Client <br />