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m r r r r r r m mEll <br /> r r r r rr rr r r <br /> 720 Olive Drive, Suite D <br /> .�� Davis, CA 95616 <br /> Lab 530 297 4800 <br /> ANALYTICAL ccc Fax 530 297 4803 Lab No s t�& Page { of �- <br /> Project Manager Phone No <br /> To� Rq U,.W ~r (9 tt) 35 �_ 3-J�o Chain-of-Custody Record and Analysis Request <br /> Company/Address FAX No <br /> Analysis Request <br /> Project Number PO No Email Address o <br /> ❑ pdf El As ❑ doc ❑other NN LU <br /> 3 1- <br /> Project Name Sampler Signature m m m �' <br /> rII m X E <br /> 0 LU L 3 O <br /> Sti1r?k �it '! ��it�iC{IL �.r �'ifte4' N m � a <br /> Project Location w �, o w � o °� w ° t a <br /> CD m a C7 o w ¢ N 1 7 <br /> �i.,r1l 1�q k %tMtfer Lqyt 5tct(cto � s N V o o N <br /> Sampling Container Preservative Matrix y o N N 3 °1 . <br /> P g m N N N u- <br /> ` N <br /> �' O � 0 <br /> Q W O = O m C C C 7 G N L LL <br /> p � > o W w °� o m m m <br /> Lu <br /> Sample o Ca Z W O ¢ O W a d d O O O Q M a o m N <br /> Designation Date Time � 0 _ _ L) Z m m ►- � L Lo r- J W <br /> C PT 3-44 314I0x B55 <br /> CPT �- IIQ 1000 1x oZ <br /> ctr3 - 140 10103 x x X X '23 <br /> C P 1* X <br /> C{'T 't' 1335 3 X x X x x X as <br /> UT 1411, 3 X x X x x X 06 <br /> PT 't - (50 1500 3 X X X X x x 07 <br /> � <br /> CPT (b - tz0 920 31 1 1 4 1 1 1 1 X x x x x x 10 <br /> Relin uished by Date Time Received by Remarks <br /> 10 <br /> yl <br /> Relinquished by Date Time Received by <br /> T' <br /> Relinquished by Date Time Received by Laboratory Bial to F k w k J JuoiE Iry i'N wr►I I <br /> ax zs ,6 F� 9,0 Box ? 6";l Rgiicht K41irlitw rA <br /> Drstnbutron White-Lab Yellow-Fila Pink-Ongrnator Formslcoc 062801 fh9 <br />