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I• —�■�■-- I L w <br /> BSK Lag Number ANALYSIS REOUES;ICH F CUSTODY RECORD / <br /> Client Name Prote ,gr PO M Analysis required <br /> Ch Pj- G1 fIZv��p� Lab Use Only <br /> Address / Phone# !/ in this <br /> f/aY® r O 7�o 2" section <br /> City Slate Report attention / `i ` N �_ l <br /> Sampled by ' Number Lab Sample `a <br /> Type </f r✓ seals <br /> Date Time ' of Sample <br /> sampled sampled :See } Sample descriptxx+ ontainers number (See key ,( r� Remarks <br /> below) <br /> X <br /> Yr x x x <br /> IMPORTANT NOTICE No samples will be analyzed without an authorized signature in this section <br /> ing BSK s Formal Ch <br /> am hereby requesting BSK s Normal Chamawith <br /> those <br /> Chain-of-Custody outlined in US EPA Contract Laboratory Program State <br /> these procedures are generally consistent with those outlined Procedures far the above samplesI understand that <br /> f-Custody Procedures for the above samples I understand that I am hereby requestawin the US E PA SW 846 and that there is no these procedures are generally consistent with <br /> mart of Work Section F end that there is a charge of$5000 per work order or S5.o17 a bottle whichever is <br /> extra charge for this service <br /> greater <br /> By By <br /> AAuthorized Signature <br /> Authorized Signature <br /> Signature <br /> Print Name Company Date Time <br /> Relinquished by <br /> Received by <br /> Relinquished by <br /> Received by <br /> Relinquished by <br /> Received try <br /> }(EY Type AQ-Aqueous SL-Sludge SO-Soil PE-Petroleum OT-Other <br /> 3SKSeals P-Present A-Absent B-Broken& Associates Chemical laboratories DISTRIBUTION WHITE,CANARY-LABORATORY PINK-ORIGINATOR <br /> Note <br /> Samples are discarded 14 days after results are reported unless other arrangements are made. <br /> 1414 Stanislaus Street Fresno, California 93706 Hazardous samples will be returned to client or disposed of at client expense. <br /> Telephone(209) 485.8310 0 fax (209) 485-;427 <br />