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CHAIN OF CUSTODY RECORD BCA Log Number <br /> Client name Project or POk <br /> j, Analyses required <br /> IVED <br /> Address Phone p rV <br /> t <br /> �! Y 1a k ► .E.S.T. <br /> City,Stats,Zipr, Report attention <br /> C A ° ate <br /> !ed � y c <br /> Lab Type' Sam \ Number o�ra <br /> Sample Date Time See key r 1'�' of <br /> number sampled sampled below Sample description containers g� Remarks <br /> mfr Cis�`t�. <br /> - <br /> Signature Print Name Company Date Time <br /> Rolinquished J l <br /> Received by <br /> Relinquished by <br /> Received by <br /> Relinquished by ��11 <br /> Received by Laboratory VY <br /> v <br /> 8 C ANALYTICAL _ Note:Samples are discarded 30 days aryer results are reported unless other arrangements are made. KEY: WW—Wastewater SU—Surface Water SO—Soil <br /> ❑ 1255 Powell Slreel,Emeryville,CR 94608 {510)428-2300 Hazardous samples will be returned 10 client or disposed o1 at client's expense. SL—Sludge PE—Pelroleum OT—Other <br /> ❑ 801 Western Avenue,Glendale,CA 91201 (818)2475737 disposal arrangements: NA—Nonaqueous GW—Groundwater AQ—Aqueous <br /> ❑ 1200 Gene At y,Anaheim,CA 92805 (714)97801 13 a <br />