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a:g <br /> 1�Bttraftnnar Inc. <br /> BEACON <br /> CIiAIN OF CUSTODY REPORT <br /> urrrnmir <br /> ate Form No. <br /> Beacon Station No. <br /> Sampler(Print Name) ANALYSES •3 is f 1 of <br /> Project No. ! Sampler <br /> z�n(--Sig'nature) c ��^ <br /> it OF rrMn}�" aCUd�� <br /> Affiliation ` o h o �JlLr�fj t <br /> Project Location <br /> JZ`v !el-ill, uX.1 S Y <br /> CL <br /> Date Tim c <br /> Lab No. m r t — z REMARKS <br /> Sam to No/identification <br /> ------------- <br /> S i3 1 r3 <br /> pate Time <br /> Date Time ROC ed by:(SignaiurehA filiation} <br /> Relinquished by:(Signature/Affiliati n} Ids /V/ <br /> /KD e Time <br /> tC�L C��G Date Time Rece' ed b :(Sign e! 'talion) � <br /> Relinq hed by:(SignaiurelAl'talion) <br /> Dae Time <br /> Re i ed ur Affiliation} <br /> Relinq ished y:(Signat A iation) Dat T/ime �Signat ; <br /> LJz, ` <br /> . �f/� Bill to: ULTRA I AR INC. <br /> Report o: r 6-tT 525 West Third Street <br /> f Hanford.CA 93230 `4 I �(1�jfiJJ5b f� <br /> OIL, t "r! Attention: <br /> w_ <br /> WHITE Return to Client with Report <br /> YELLOW:Laboratory Capy PINK:originator Copy <br />