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I • PLEAS MPLETB Y <br /> Laboratories Inc. BCLQvaTBID <br /> Cham of Custody Form <br /> Repon To i - !L,NI36558 Pae of '2 <br /> Client Project#` g <br /> Attn 4� Pro ect Name Comments. -- „ �- <br /> Street Address 21 Project Code w , r � �.� <br /> ' t o to he bta k t t t is <br /> City,State Zi l� <br /> Sampler(s). ;�` (11" 't] l tit i A <br /> Nouniatu sI � <br /> Phone - .. ax ' � 1 zD �r "T bu��ov�1$ it ;inn is r it In alt <br /> Email Address: oc Oil(�5 Sample Matrix Are there any tests with 48 dinghours"" leas than <br /> OJ 'sC (�, �. .a�, or equal to 48 hours <br /> w q ss <br /> R iC ;; px <br /> Submittal Yes N4#. 3 3 <br /> 0 <br /> Description <br /> Date Time 4c c o *Standard Turnaround= 15 workdays <br /> �Cample :1 <br /> " ° <br /> ' • • v°�n 0 3 Other <br /> ._ 1 D 1 <br /> r �� n t <br /> �0 3z <br /> t <br /> �- 1C ID19 <br /> ❑ Same as above Report DriQEuag <br /> Sample Disposal Special Reporting <br /> ® Waters on State Form9 ❑ Return to Client ❑ Disposal by lab ❑ Archive Months---- ❑ QC ❑ WIP ❑ Raw Data <br /> Client• ❑Yes ❑NO 1 Relinquished By Date Time 1 Received By Date Time <br /> Address ————— ��� f <br /> Cl State 71 Sed Copy to State of Relinquis Date Time 2 Received By Date Time <br /> City. P CA, Ot-�'1 SD <br /> Atttsi LI Yes ❑NO �V�UA 1 <br /> 3 R linquished By Date Time 3 eive Date Time <br /> Po#: - -D zlz 21?-5 <br /> BC Laboratories,Inc.-4100 Atlas Ct.-Bakers 3308-661327.4911-Fax 66132 71918-www Mak ca <br />