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mmf� mom MM MMM. 401 <br /> Centrum Analytical Laboratories, Inc. Centrum Job # qO I <br /> 290 TENNESSEE STREET (909)798-9336•(800)798-9336 <br /> fa ' <br /> " �DLANDS,CA 92373 FAX(909}793-1559 <br /> Chain of Custody Record <br /> Page of <br /> Analyse Requested <br /> Project No.: Project Name: <br /> — _� L n m ' °n Tum-around time <br /> Project Manager: P e: Fax:62QEl24 Hr RUSH" <br /> A . M/LG 7/ -770. 7G— l <br /> C3 <br /> <A o ' a ❑ 48 Hr. RUSH` <br /> ! Client N me: Address: /7 7,5 Ua� I'"/FrQ�-lif.r� +U . ❑ Normal TAT <br /> {COrnpany he-r/ E a ss •As7ukn p�aaa� <br /> Y o �� « _ « wamrwwoesapply <br /> 0 <br /> Date Time v, <br /> Centrum ID Sample i Sample Containers:' <br /> D nta Hers: <br /> pi Ai o. � Remarks! <br /> (lab orae only) ye a Mould appear oh report) Sampled sampled matrix Site location #and o F <br /> Ii a type c o o . _ Special Instructions <br /> 8 i to W a <br /> . D L <br /> 0 <br /> 13 mwi -30 3: <br /> lot "01 <br /> a <br /> C f' <br /> h •3?> <br /> R :[ eYs SI Da' Arne Rail shed by: Date Arne <br /> "' /'�(", To be completed by laboratory personnet: Sample Disposal <br /> hy: Date eceived by: Zri 1/-)041; <br /> ppta nme' samples chilled? Yes 0 No <br /> Custody seals? ❑Yes No ❑ Client will pick up <br /> Relinquished by: Dabs nme �Ll <br /> The delivery of samples and the signature on this chain of custody form All sample containers Intact?�I Yes ❑No O Return to dierd <br /> constitutes authorization to perform the analyses specified above under R elvad � � ❑liPSlFed Fx O1 Hand carraed <br /> the'rerttis and Conditions.id forth on the back hared. 0 Lab disposal fee$5 <br /> r*' <br /> LaSora�wy Ndes: ���` Sample Locator No. <br /> Nov 171g�'� <br /> 1 . <br /> White Copy-Orir/rlat(Accomtwties 5amaes) Yeptaw Copy-t;arThtrm Flies �'k�.► Pink Copy-Arent Copy <br />