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i1 Miramar Inc. BEACON <br /> ' <br /> CHAIN OF CUSTODY REPORT <br /> Beacon Station No Samp (PrintIiI <br /> D e Form No <br /> r� M5,c/k� ANALYSESof <br /> Protect No Sampler(S n <br /> Protect Location AffiliationCD <br /> w <br /> N w O <br /> d' GAJ 5A9 V I MMMLIA1 a ( X rn U <br /> 0 <br /> Sam le NoMenlification Date Time Lab No m �z REMARKS <br /> (.tJr O'fe-?,O 3elf` <br /> /,/,i <br /> R i hed ytgnature/Affiliation) Date Time Received ( ur i i Date Time— <br /> ///� <br /> 1-&/ 1.10 i <br /> Reiinquis ed y S at n Date Time Rec w qlgn,a Affi is on ime <br /> 3 <br /> R®linaua h y (S 10 Date Ti a Received by (Signature/Affr ate Time <br /> Report To (301A <br /> r L.J�r 1 P� � Bill to ULTRA INC <br /> ('� 525 West Third Street <br /> �1 Hanford, CA 83230 <br /> `d�X • 976 q,37 —217Z Attention <br /> ,.WHIT*turn to Client with Report YELLOW Laboratory Copy INK Ong�nator Copy ue <br />