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• PLLA.-,, OMPLL-TF_: <br /> Laboratories, Inc. Chain of Custody Form t3�LQGU� 1D <br /> f;.lien, Analysis Requested 52799 <br /> Client: c Project#: �!t?S fly' Page '?=• of <br /> Attm An ct Project Name: L y Comments: <br /> Street Address: 2 nr Project Code: j S j 9 <br /> V <br /> - <br /> City,State,Zip: G" Sampler(s): <br /> Phone 1 g41V Fax <br /> -" Are there an tests wit <br /> Email Address a '} - }� «r, hlo J' ASO Sample Matrix Y h boldin,:times tens than <br /> b �, or equal to 48 hmirs? <br /> Submittal# 5- 16 fl- 3 3 ❑ Yes ❑ No <br /> Sample DeSeription D !� ❑o v <br /> . <br /> n- v °b �' *Standard Turnaround= ZS work da s <br /> # Sampled Sampled <br /> kol 04 ce);7i Q other Notes <br /> —p 1L1 — tai o U;2D Nskl a��zs w//lzt� <br /> _15- - a"D <br /> A_ J `1L, <br /> /-41v-13 b-7 C9 <br /> t uo-2 o` 5--d <br /> ALo -lo —Wt/ p� <br /> co <br /> Same as above Report Drinking Sample Disposal Special Reporting <br /> - Waters on State Form? ❑ Return to Client ❑ Disposal by lab ❑ Archive: Months__________ ❑ QC ❑ SNIP ❑ Raw Data <br /> ❑Yes ElClient• No 1. Relinquished By Date Time 1. Received By Date Time <br /> • <br /> Address: ——— Z?6N I(- /tloo t ,�-- /-/Z" <br /> Send Copy to State or 2• Relinq4 <br /> uis a Date Time 1. c vet hyn t Dat Time <br /> City: State Zip CA, [>�-�I•ui � �`J1 � <br /> Attn: ❑Yes ❑ NO a inquis By, Dale Time 1. ived By ate Time <br /> Po# 3 X35 sc <br /> BC,Laboratories,Inc.-4100 Atlas Ct.-Bakersfield, CA 93A8 Z11-327.4911- 'ax:t56L3 7.1918-www.bclabv combqF.1 rgjqq,..t 9131 /1-15, <br /> Zl� <br />