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M M M M M M M M M M M M M M M s M M M BSK Log Number ANALYSIS REQUEST/CHAIN OF CUSTODY RECORD 1000- 7452 Client Name Project or P.O.N Analysis required Lab Use Dory Address Phone A In this ` t-, section City,State,Zip // Report,a8entIon el/r /01-0 Sampled by Sample (ILEA Number Lab p Date Time / �i 1 P. C�[ of Sample Seals s sampled sampled Seabebve ainers number (Sea key Remarks ,2• Sample description below fl 110 or i I 4 I I i IMPORTANT NOTICE: No samples will be analyzed without an authorized signature in this section. I am hereby requesting BSK's Normal Cham-cf-Custody Procedures for the above samples. I understand that I am hereby requesting BSK's Formal Chain-ot-Custody Procedures for the above samples.I understand that these procedures are generally consistent with those outlined In the U.S.E.P.A.SW 846 and that there Is no these procedures are generally consistent with those outlined in U.S. EPA Contract Laboratory Program Slate- extra charge for this service. ment of Work,Section F,and that there is a charge of$50.00 per work order or$5.00 a bottle,whichever is !7, 1 / .1�6 greater. By: I Authorized Signature ri Authorized Signature Signature Print Name Company Date Time Relinquished by .•>1 ' -40" y. 1` a /z { (O ri:: ?=-f C /<- •` / l' 1.:/.^ � .tet � �•./ �.. ..I N � Received by •. Relinquished by F Received by Relinquished by Received by BSK KEY: Type:AQ-Aqueous SL-Sludge SO-Soil PE-Petroleum OT-Mer'l,',.•: l i Seals: P-Present A-Absent B-Broken & Associates Chemical Laboratories DISTRIBUTION:WHITE,CANARY-LABORATORY PINK-ORIGINATOR Note: Samples are discarded 14 days after results are reported unless other arrangements are made. 1414 Stanislaus Street Fresno, California 93706 Hazardous samples will be returned to client or disposed of at client expense. Telephone(209)4858310 • Fax (209)4857427