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1� e• V <br /> y' <br /> CHAIN OF CUSTODY RECORD <br /> SAMPLE (signatur <br /> Ain K p�:11 41fl spin/i�d Gea�ystem� <br /> 4191-E Power Inn Road,Sacramento,CA 95826 (9161452-2901 <br /> E Phone: •i--- <br /> •Fremont •Costa Mesa •Sacramento <br /> LABORATORY: 1 r SHIPPING INFORMATION: <br /> f QIlr f-vJ2�lay <br /> Shipper <br /> Address <br /> r Q /Y1{) Date Shipped <br /> TURNAROUND TIME: `L�+`�l=1rt��� zrN4�P Service Used <br /> Attent[on: r�I'S l��r��'�.I�� _ Afrblll No. Cooler No. <br /> Phone No. +I( 5 <br /> Rellnquis adby:(signallures). Received by:(signatures) Date Time <br /> � - I Y:yp <br /> Receivo-t laboratory by:, <br /> ABORATORY SHOULD SIGN UPON RECEIPT AND RETURN A COPY OF THIS FORM WITH THE <br /> LABORATORY RESULTS <br /> Sample Site Date Analyses Sample Conditlon <br /> No. identification Sampled Requested Upon Receipt' <br /> — Is apt t j1pu�,!j G 1 <br /> i <br />