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rYANALYTICA[ <br /> .._,...dArOMES,INC. <br /> CHAIN OF CUSTODY RECORD AND AGREEMENT TO PERFORM SERVICES <br /> Project* Purchase Order# ❑LGN -MRG THIS AREA FOR LAB USE ONLY <br /> 15141 1 �`� One Innovation Drive,Suite C 5090 Caterpillar Road Lab III Page of <br /> `1 � �,1 Alachua,FL 32615.9586 Redding,CA 96003-1412 <br /> Project Name ! t1 rl <br /> (904)462-3050 FAX{904)462-1670 (916)244.5227 FAX(916)244-4109 <br /> ❑LMG ❑LKW <br /> r rn •I`� �r tc�l7 <br /> 2567 Fairlane Drive Canviro Analytical Laboratories,Inc, Client Service Price Source <br /> Company Name Montgomery,Al-36116.1622 50 Bathurst,Unit 12 A P O S <br /> ��1 1���` (334)271.2440 FAX(334)271-3428 (519)747-2575e o,Ota FAX(519)747-3806 V2C5DEL <br /> Pro Manager or Contact• i)&Phone#e Report Copy to: ANALYSES REQUESTED Acct Code Test Group <br /> Requested Completion Gate: Site ID Sample Dlspoaal: F � Project Code Adc.Gen. <br /> I)IWG Return <br /> ElN- m <br /> � r <br /> T LIMS Ver Login MOIL <br /> Type rixi A 'RV <br /> r <br /> Sampling o R a o CLIENT SAMPLE!D OC!D N v-' a '� COG Review <br /> P e E 1 (9 CHARACTERS) (3 CHAR) R <br /> Date Time R s � �► N SAMPLE REMARKS LARD 1 LARD 2 <br /> I'S _ I IM W. — . I <br /> r �7 �� • b <br /> 9�a ts b <br /> + -- 9 _ V, 014_17 r VA7 W an r. TI m <br /> pled By 6 Title L`f son and mel a Relinqul By ana p:e �t b NAZYVRAPMESSA Y N <br /> wed By t sqr and prig rsvne) em a Rellnquls By t syn ane Pru name) V f e EDATA: Y N m&LblnbL, 103p I — <br /> Racelved By (Pwm sloe and prm name)) e lite Relinquished By fPwasa sign and�r narrei DatelThe <br /> CC LEVEL 2 3 OTHER <br /> Received By (rrase aipn and prix r,ema) DatsTTime ShlpuPS� Fed-Es Other �l�1 t�84-�20 s�esl°d'I N Tan, <br /> � <br /> Balch Remarks: <br /> Instructions and Agreement Provisions on Reverse Side DISTRIBU71ON.Original- IAB,Yellow- LAB,Pink-Client <br /> REV 5195 IAB FORM 340 <br /> 4 <br />