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4- <br /> F <br /> � <br /> CHA A OF <br /> CUSTODY REC JRD <br /> SAMPLER Wsnattwa): y, .eF�7�ii�d Ge���St�ms <br /> Phone: '- ;A L� 13:57 .%w;ion Blvd. Suite B Fremcmi.CA 945T) 1415)b'51-190b <br /> LABORATORY: SHIPPING INFORMATION: <br /> Sh'spper <br /> Address <br /> ..®. 2�—MPA,'_r 67,"- 7 Date Shipped <br /> TURNAROUND Tlliot;: `�S' '' �"� Service Used <br /> Attention' AtrbiIINo. Cooler No, .. ... <br /> Relinquts"d hy.*/(signat rou) , Received by:(signatures) Dat® Time <br /> I� <br /> 1 <br /> Received to ratorp by <br /> �mac,-✓� 1"'�tf-d 7 <br /> BORATORY SHOULD SIGN UPON RECEIPT AND RETURN A COPY OF THIS FORM WITH THE <br /> LABORATORY RESULTS <br /> Sample Site Date Analyses Sample Condition. <br /> No. Identificatign Sampled Requested Upon Receipt <br /> 3 <br /> r(j:f �' !C=.� <br /> ON <br /> OF THIS <br /> T R <br /> DUE TOT <br /> l OC ON Cr TW <br /> ORIGINAL <br /> ON <br />