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Ultramer Inc. �Ov 3�, BEACON <br /> duirwnw <br /> CHAIN OF CUSTODY REPORT <br /> Beacon Station No, Sampler rin Nam } Date Form No. <br /> L�17 IG/1, o��F eti ANALYSES -/ - of <br /> Project No. Sample ter ) <br /> _ <br /> Project LocationAffiliation v <br /> c�cfa,t� 4y'M40n0 ENv. I/JG . <br /> X <br /> as rZ061 <br /> Sam le Nolldentification Date Time Lab No. m o. REMARKS <br /> cv—o `13 <br /> 7 <br /> Relin ed b : (Si naturelAffiliation) Date Time Received by:(Signature/Affiliation) Date Time <br /> rY 4� <br /> Relinquished by:(Signature/Affitiation) Date Tim Received by: (Signature/Affiliation) Date Time <br /> Relinquished by: (Signature/Affiliation) Date Time Rived by: (Signature/Affiliation) ate Time <br /> y <br /> Report To: / _ Bill to ULTRAM IPC. <br /> 525 West hird Street <br /> Hanford, CA 93230 ,- <br /> 61,0 r 72 U Attention: 46uwf �crr <br /> WHITE: Return to Client with Report YELLOW: Laboratory Copy PINK:Originator Copy � � <br />