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ll>� .- r s~ I� ii i� w I' lid I� r■i � � I� � Y <br /> U or Inc. BEACON <br /> CHAIN OF CUSTODY REPORT <br /> Beacon Station No. Sa ler(Print Name) Date Form No. <br /> ;'r ANALYSES n~ll. 912 of Z <br /> Project No. Sampler nature) , <br /> j Project Location i!i is' n = co •� <br /> d3 r C)L r <br /> Sample Noildentitication Date Time Lab No. m � 21 REMARKS <br /> 12 <br /> S -ANZ) <br /> /b, nS 3 I <br /> Rel' quish y:(Sig re/Affiliation) Date Time Received by:(Signature/Affiliation) Date Time <br /> elinq shed :(Signature/Affiliation) [Date Time u Receivedb�r: �gnature/Affiliatia ) Ibafe Time <br /> Relinquished by:(Signature/Affiliation) Date Time R ived by:(Signature/Affiliation) Date Time <br /> j ( i <br /> Report To: Bill to: ULTRAMA INC. <br /> 525 West hird Street <br /> Hanford, CA 9323 // N`� c <br /> Attention: l�/ 16171 7.lVi Cam<rw' <br /> WHITE: Return to Client with Report YELLOW:Laboratory Copy PINK:Originator Copy '2-'0° IM <br />