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F BSK Log Number ANALYSIS REQUEST/CHAIN OF CUSTODY RECORD 1000- 0524 Client Name ^ .�^ Project P.O.M , SS A5Scc IC� A{,, CIS? Analysis required r'� lJ Lab Use Only � Addressjj�� Phone in this 57Z(Q F-7S�/1lo✓ylCX Dr YlS bZ - 116100 section � City, tate,Zip Report, attention � Z� ,^ �0 �� FIGURE 25 tL1:�Lt.S C.� Qys66 Sampled b ya p y Sample Date Time S�kk !!I� s� Nu Of Lab Seals sampled sampled k Q' below) Sampled ription ntainers number ( key below) Z�gQ� Remarks K 5& SO g -� :(�. / e- / �L / l '� �f W-5 (v-) 6/a; AM) SO1 -5 .,(.b 1'/� ' >c x � . �;��s e o AVel IMPORTANT NOTICE: No samples will be analyzed without an authorized signature in this section. I am hereby requesting BSK's Normal Chain-of-Custody Procedures for the above samples. I understand thatI am hereby requesting BSK's Formal Cham-of-Custody Procedures for the above samples. I understand that hese procedures are generally consistent with those outlined in the U.S. E.P.A. SW 846 and that there is no these procedures are generally consistent with those outlined in U.S. EPA Contract Laboratory Program State- extra charge for this service. lJ ment of Work, Section F, and that there is a charge of $50.00 per work order or 55.00 a bottle, whichever is //�� greater. By: �— By: Authorized ignature Authorized Signature /Signature Print Name r /Company Date Time Relinquished by [ Q/-�' �7y1/1 Received by CA Relinquished by Received by Relinquished by Received by BSI ` KEY: Type: AO-Aqueous SL-Sludge SO-Soil PE-Petroleum OT-Other Seals: P-Present A-Absent B-Broken & Associates Chemical Laboratories DISTRIBUTION: WHITE, CANARY•LABORATORY PINK-ORIGINATOR Note: 141.3 Stanislaus Street Fresno, California 93706 Samples are discarded 14 days after results are reported unless other arrangements are made. Hazardous samples will be returned to client or disposed of at client expense. Telephone (209) 485-8310 • Fax (209) 485-7427