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3HAIN OF CUSTODY RECORD 2870 GATEWAY OAKS,SUITE 300 <br /> ISE A BALLPOINT PEN AND PRESS FIRMLY SACRAMENTO,CA 95833 l J <br /> HE INSTRUCTIONS FOR FILLING OUT PH. (916)679-2000 16 012 <br /> HIS FORM ARE ON THE BACK URS FAX (916)679-2900 <br /> TASK OR SUB TASK(one per form): LABORATORY AME AND�ADDRESS: I THE INFORMATION IN THIS <br /> SECTION WILL NOT BE <br /> CONTRACT NAME: AVAILABLE TO THE <br /> CHARGE NUMBER: LABORATORY <br /> COLLECTION <br /> J__ <br /> SAMPLE NUMBER DATE TIME CONTAINER TYPE <br /> Oc S— I 2 IOIS CM1 4 ,t VOA W6 /-{, 06,6,,001 ✓OQ m �I <br /> 0cs - 1 3jr/lt- 1alS ck4l I 250 pol y (aG /Uoht AIIVAfe5 OI <br /> 6W01 alkl 51 qoMt;,-04 v& ly-tl(- UQ0,6kO, V6C5,fur/s �z 3 <br /> C W o l !Z JOT CO- Z50 PolyIii1fW 3 02 <br /> GWo91- i 1Z 12sU OVL s gOk�I VOA W6 46,fL c*v, NO, to" o3 S <br /> GWOZ 31�('(yI Iz5V CAW- 1 a50 pol q W yWo5 T1 IR 2ztU+1-s(NXD) o3 <br /> 515/121315- CML 5 q0n t VOA W 6 Hu— OeO) QkOz VOC-3 J q 97 <br /> 0111V03 3/5-11L 131 1 '2s0 pol wc, PW3 1- jt I2 sDf <br /> 12 <br /> /11 <br /> REL D BV DATE TIME COOLER <br /> COOLER ID: SAMPLING COMMENTS: <br /> �' . COMMENTS: <br /> RECEIVED BY DATE TIME RELINQUISHED BY DATE: <br /> CD <br /> 103 '2 <br /> 1633 <br /> p DISPOSAL CONFIflMED DATE TIME CHAIN•OF•CUSTODY RETURNED BY DATE TIME <br /> YHITE-COORDINATOR •PINK-SAMPLE CONTROL•YELLOW-LABORATORY <br />