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� � � � � � � � r � � tr itttt>• � � <br /> Ultra Inc. <br /> BEAC N <br /> CHAIN OF CUSTODY REPORT <br /> manor <br /> Beacon Station No Sampler(Print Name) Date Form No <br /> 4 <br /> 1 / r/{� ANALYSES 7-1,72_9413 of <br /> Project No Sam p ignature) <br /> Project Location Atfdiatbn o �pY tit 4 <br /> 5 U �!/ 7� co Q o <br /> { 1 ��✓ c}� � ZOO w =�? o Tw�r <br /> Sample NoAdentificatwn Date Time Lab No m � �_i I a z° REMARKS <br /> -22- SSI -n 6 <br /> IHO <br /> O r <br /> 83 <br /> Re uished by (S ature/ ffiliation) Date Time R iay (Signature) ff�6at� n} Date Time <br /> err' -� 723 G' a 3 <br /> Reli ed by (Signa / is ion) Date Time Received by (Signatur Affiliation) Date Time <br /> Relinquished y turetAffiliation) Date Time Received by (Signature/Affiliation) Date Time <br /> Report To Bill to ULTRAMAR INC <br /> �Cf Ir y i2a rk,P` 525 West Third S reel <br /> Ho /U Hanford, CA 93230 <br /> Attention �G �q �� LT <br /> '�"°°"�° <br /> WHITE Return to Client with Report YELLOW Laboratory Copy PINK Originator Copy <br />