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&MMMIrm, BACON <br /> CHAIN OF CUSTODY REPORT <br /> Beaoon Station No. SamplerPrint Name) Form No <br /> y I Marr S0E&V&rv, 1Jam, ANALYSES 1Zat 7 R 4 <br /> Project No Sampler(Signature) a <br /> 1(0441. !qV/44 L:� <br /> Project location a,►,w .Or LaN►e. Affiliation � " � <br /> i�ar'v�ip� �oriZOh �v►� ir�wti��� Sh � <br /> � c <br /> Sample NoAdentfication Date Time Lab No I IZ REMARKS <br /> • 55- 43 <br /> 525- $3 -os <br /> 530- 83 - 6� t <br /> S35_ g3 -07 <br /> f Seo- 63 0� � <br /> Reli ish by:(Signatu At nation) Date Time Received by Signa tae Date Time <br /> �� <br /> Relinquished by (Signatur Affiliation) Date , Time Received by (S ffi6ation) Date Time <br /> Relinquished by.(Signature/Affili i Date Time R eived by Signature/Aff kation) Date Time <br /> U 9Q - , <br /> Report To I to ULTRAMAR INC <br /> 525 West Third Street <br /> &dry Hanford, CA 93 0 Attention Ti0G �I r r <br /> do c- <br /> WHITE:Return to Client with Report YELLOW Laboratory Copy PINK Originator Copy <br /> i <br />