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M 0016 41 CT CHEMTECH ANALYTICAL LABORATORIES (916)635-3962 CHAIN OF CUSTODY- LOG-IN <br /> PROJECT NAME // ANALYSIS DISPOSAL RESULTS VERBAL <br /> 4 03 fr <br /> PAGE CLIENT CHAIN OF CUSTODY# O ¢� �� �� Yes ❑ No ❑ <br /> OF Z Z lj QO O Gj DATE BY <br /> CHEMSAMPLE I D DATE TIME MATRIX O [ p�� k��JQ�'� � TO WHOM <br /> TECH SAMPLED SAMPLED PHONE <br /> ID # <br /> COMMENTS <br /> SAMPLED BY ❑ CLIENT ❑ CHEMTECH ❑ OTHER <br /> REPORT TO <br /> RECEIVED VIA ❑ FED-EX ❑ U P S ❑ CLIENT ❑OTHER <br /> I <br /> INVOICE TO <br /> ZIP <br /> ATfN <br /> ZIP <br /> PHONE <br /> ATTN PO # <br /> Relinquished by (stgnaturel Dale/Time Received by (Signature) <br /> FIELD SERVICES ❑ NO ❑ YES ❑ ATTACHED FIELD REPORT <br /> Relinquished by (signature) Date Time Received by (signature) DISPOSAL OF SAMPLES ❑ NO ❑ YES <br /> IJ NO OF SAMPLES @RATE $TOTAL <br /> Relinquish d by (signature) ate/Time I Recety for Laboratory by <br /> �j� (s. el CLIENT(SIGNATURE) <br />