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• . Pagc ( of _ <br /> CA : bp Chain of Custody Record 4,� r on-site Tirnd3/S Temp: 640 <br /> Project Name ,��� Off-site Time ofa Temp; o <br /> 8P 31x1/(.'.]N M CO Pvrtt'alio: �!e w Sky Conditions &Pe__ <br /> / 13P Laboratory Contract Number: Meteorological Events: i&— <br /> Requested Date: Requested Due Date(mm/dd/yy) <br /> 7 s,}�d, Qa" Wind Speed: Direction: <br /> S¢nd T'0: BMEM Facility No,: 59T —' <br /> Consultant/Contractor: <br /> Lab Nanie, _ 13P/GEM Facility Address: t7 <br /> I.,ab Address:[ LJ Address: <br /> '�`� _�- �( Site ID No. !_ <br /> Site Lat/Long: <br /> e-mail EDD: <br /> Q' <br /> `+'ti California Global ID d1rt o oa ! T Consultant/Contractor Project No.: <br /> Lab PM: '�" , BP/GEM PM Contact: Consultant/Contract Tele/Fa <br /> 'I'ele/l�'a � O Address: <br /> Ttepnri'Type&QC L.evcl; Consultant/Contractor PM. <br /> 13P/GEM Account No.: Tele/Fax; <br /> Invoice to: Consultant/Contractor " Circle one) <br /> � BPIGEN Work Release No: <br /> Lab Bottle Order No: Matrix Preservatives I Requested Analysis <br /> Item <br /> Sample Description Time 3 � Y � N x <br /> No. � � � Laboratory No. � � o �U pp o .1., � Sample Point Lat/Long and <br /> P t` <br /> a3 o O 00�. CIO Comments <br /> rn <br /> 1 L.- 5 x <br /> Js3 <br /> 4 a.• y • <br /> c,-- •rte <br /> x �° )eI >t <br /> 7 <br /> 8 --- <br /> 9 <br /> -- COD EREM RATURE e <br /> 10 <br /> Sampler's Name' Reliuqutshed$y/AfrdiationDate Tietse Accep�cdBy/AiTilt 'ou Date Time ��,� <br /> Sampler's Company: <br /> Shipment Date: <br /> a <br /> Shipment Method: <br /> Shipment Tracking No: ik <br /> Special Instructions: <br /> on <br /> Custody Seals In Place-Yes--W No A Temperature BIank Yes No `-~ Cooler Temperature on,Receipt °F/C Trip Blank Yes No <br />