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m4r:2" M M M M <br /> _BSK Log NNAL REQ IT/ FIMODPRAM � l � <br /> umber <br /> Client Name Project or PON Analysts required <br /> � �. 0 ! r 3 Lab Use Only <br /> Address Phone N in this 1 <br /> ( vQi' C �j� C - D6) section a <br /> City State i Report attention ��A� �U <br /> e <br /> z✓G,'?/stern <br /> Sampled by Number lab Sample y` i / ��\�� <br /> Date Time Type /�� of Sample Seats ^N\, R n <br /> sampled sampled � ? Sample description ontamers number Y` r� Remarks <br /> beer <br /> o <br /> ;t <br /> x <br /> o r x <br /> 6/1 .57- T 9 K x N I <br /> IMPORTANT NOTICE No samples will be analyzed without an authorized signature In this section <br /> I am hereby requesting BSK s Normal Cham-0l-Custody Procedures for the above samples. I understand that I am hereby requesting BSK s Formal Chainvl-Custody Procedures for the above samples.I understand that <br /> these procedures are generally consistent with those outlined in the US. E PA SW 846 and that there is no these procedures are generally consistent with those outlined in US. EPA Contract Laboratory Program State- <br /> ment of Work Section F and that there is a charge of 55000 per work order or MOO a bottle whichever is <br /> greater g <br /> By ��'" y Authorized Signature <br /> Authorized Signature <br /> Signature <br /> Print Name Company Dale Time <br /> Relinquished byQ f r e- <br /> Received by d`"ti° <br /> Relinquished by <br /> Received by <br /> Relinquished by <br /> Received by <br /> KEY type AO-Aqueous SL-Sludge SO-Soil PE-Petroleum OT-Other <br /> BSK <br /> Seals P-Present A-Absent g-Broken <br /> & 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 ctient expense. <br /> Telephone (2091485-8310 • Fax (2091 4857427 <br />