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720 Olive Drive, Suite D <br /> .�� Davis, CA 95616 <br /> Lab: 530.297.4800 <br /> ANALYTICAL ccc Fax: 530.297.4803 <br /> Project Manager: - Phone No.: Lab No. Page of <br /> ( 9 t 6 ) -3 5 4 - 32 5 0 Chain-of-Custody Record and Analysis Request <br /> CompanylAddress: FAX No.: <br /> R w" 'ky e. k h v i r a 1 * e h t 0 k6 ) 3S4 - 1 -+ $ b Analysis Request a For Lab <br /> Project Number: P.O. No- Project Name: � o oF Use Only <br /> m � w.E.T.lxi <br /> C z �� t y co v X <br /> Project Location: Sampler Signature: o TOTAL(X) <br /> Tv4� ti k ie Le., fitrm m <br /> Container Method o t7 p <br /> Sampling (Type/Amount) Preserved Matrix g — ii a N N ~ <br /> o <br /> W N M co <br /> Q lJ) g N N 2 N 6 m N SD N � <br /> 0 O Q c c c c O 4 N .c <br /> � y y 47 N N Ql 'CIO, <br /> a <br /> Sample W c� o o W z s Co C <br /> Do � N <br /> a rn T a U' z V O ¢ i- a a O O O O U <br /> Q Q <br /> Designation Date Time cn ,� z r _ z m m a. 0- n N 0 w w <br /> KW W003 x X W X <br /> M \N 1010 3 XtX <br /> W <br /> X —0 <br /> VW - 1 laLa3 x W X <br /> VW ID 10 3 W Xx -�3 <br /> Relinquished by: Date Time Received by: Remarks: <br /> Resin ished by: I Date Time Received by: Email address: <br /> ❑.doc ❑..xis ❑.txt ❑other <br /> Relinquished by: Date Time Receive by Laborato <br /> Billto: NgthtfZ �hYi'i"Q1( Imp4 N <br /> z 9�1 IZiS [..�/��6hc <br /> AI�i� Poi3 v A nR �(t? Mwr� rtw <br /> Distribution: White-Lab, Yellow-File,Pink-Originator <br /> COC.fhS(8188) <br />