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Ultramar Inc. - T <br /> 6unranuiCHAIN OF CUSTODY REPORTB�t:ACON <br /> Beacon Station No. Sampler(Print Name) Date Form No. <br /> Li 7Y ,� / ��117 S�n ANALYSES � '� _ I of <br /> Project No. Sampler(Signature) <br /> _ <br /> Project Location Affiliation <br /> Sample NoJldentification Date Time , Lab No. m ►a- I I z°i REMARKS <br /> em MR <br /> 'M 06r <br /> M �� —07 <br /> - 05 <br /> Relinquished by: (Signature/Affiliation) Date Time Received by:(SignaturelAffiliation) Date Time <br /> 11, A Al z <br /> Relinquished by: (Signature/Affiliation) Date Time U Rec ived by-.fture/Affiliatio Date Time <br /> Relinquished by: (Signature/Affliation) Date h Time 4# R ivied lby: (Signature/Affiliation) Date Time <br /> 'Q / Y A/L�t�li <br /> Report,To: Billo: ULTRA A INC. <br /> _ � 525 West Third Street <br /> Hanford,.CA 93230 - <br /> Attention: <br /> WHITE: Return to Client with Report YELLOW: Laboratory Copy PINK:Originator Copy utl00""° <br />