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Centrum Analytical Laboratories, Inc. <br /> Centrum Job # [� ��� t <br /> t <br /> 290 TENNESSEE STREET (909)798-9336■(800)798-9336 Chain of Custody Record <br /> REDLANDS,CA 92373 FAX(909)793-1559 " Page_of <br /> i <br /> ty <br /> Analyses Rec uested I <br /> Project No.: Project Name: <br /> N o Tum-around time <br /> ;Z/OV 20RAProject Manager: Phon . Fax: 24 Hr. RUSH' <br /> o a <br /> ma a _ 0 48 Hr. RUSH" <br /> Client Name: Addy s: 17 fr 7 v� i4�� $ a n o Normal TAT <br /> N pp <br /> a U rte es <br /> PatN� V , �Prwel <br /> a. 4 <br /> Centrum ID Sample ID Date Time Sample Containers: ' Remarks! <br /> (Lab use onryi (As a shodd sppew on re Site location m r; <br /> report) sampled sampled matrot #and type p aR x Special Instructions <br /> r;7 n e0 q Y t11 � J II �L <br /> d <br /> !� r <br /> Fira <br /> I� S- x X <br /> 10 <br /> AS, 6)1x <br /> Awtv*a - -5 = x <br /> o 1404,P <br /> F ry t� 2_ s -2 : �s x <br /> R by <br /> We slprnture Date Time Reil shod by; /f Date Tinto <br /> /`} X� ,� �y rJ To be competed by Iat�oratory personnel: Sample Disposal <br /> JP;e;zby: Lie, Date me Receid by: Date I Time Samples chilled? Yes ❑No <br /> r� Custody seals? ❑Yes No d Client will pickup <br /> Reliriclished by: Date Time <br /> he delivery of samples nd the signature on this chain of custody form All sample combiners intact? Yes ❑No ❑ Return to client <br /> constitutes authorization to-per(orm the analyses'spe�ifled above under R Laboratory by, me Courier q UPS/Fed Ex O Hand carried <br /> the'Terms and Conditions set forth on the back hereof. 1 "� a Lab disposal fee$5 <br /> Laboratory Notes: Sample Locator No. ; <br /> White Copy-Original(Accompanies Samples) Yellow Copy-Cwttrum Files Pink Co <br /> . ply-Client Copy <br />