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Chain of Custod3*ecord e_- t'J � on-site Time"rev Temp 40- <br /> Project Name Z f D Off-site nine rat? Temp <br /> BP BU/GEM[ CO ,Portfolio: <br /> e� Sky Conditions G e_... <br /> BY Laboratory Contract Number: <br /> Date: V Meteorologtcai Events- Qom' <br /> Requested Due Date(mm/dd/yy) — Wind Speed90- Direction <br /> �Se <br /> Lab <br /> me <br /> FIG <br /> Facility No <br /> Lab Name Cansultant/Contractor, <br /> P/GEM Facility Address AJ Address t <br /> Lab Address ( W Site ID No <br /> Site Lat/Long a-maiwm-l];I?D <br /> "+44TI <br /> alifona�a Global ID Consultant/Contractor Project o <br /> Lab PM ", P/ EM PM Contact <br /> lele/Fa Consultant/Contractor Tele/Fa <br /> O <br /> OAddress Consulta.nt/ContractorPM41,I .�� Lt( <br /> Report Type&QC Level 4.14Li„�d qjj' Invoice to Consultant/Contractor or ircle one} <br /> 13P1GI~M Account No Tele/Fax <br /> Lab Bottle Order No P/GEM Work Release No <br /> Matrix Preservatives Requested Analysis <br /> Item <br /> Sample Description Time '0 �, x t <br /> No Laboratory No. o Sample Point Lat/Long and <br /> oo d, cryo Comments <br /> l I.-A <br /> -_2 <br /> 3 ,� <br /> s ,t .•f �� <br /> g <br /> 9 <br /> 10 <br /> Sampler's Name Relinquished By/AfM adon ate ime ecepted By/A n ate MM <br /> Com an <br /> Shipment Date p I J <br /> Shipment Method 21 <br /> 3h:pment Tracking No Gf <br /> ipecial Instructions. L <br /> �ustody Seals In Place Yes No Temperas lank YeS______'Q&o v Cooler Temperature on Receipt °F/C Trip Blank Yes No <br />