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� CHAIN OF CUSTODY RECORD ENS-1145-A DATE( CHAIN OF CUSTODY NUMBEP, <br /> E/ El 2544 Industrial Ave.,West Sacramento,CA.95691-3435(916)372-1393 /O—Z z 02256 <br /> A Corning CEl 7440 Lincoln Way,Garden Grove,CA.92641-1432(714)898-6370 LAB NUMBER <br /> gom Company Y ❑18501 East Gale Ave.,City of Industry,CA.91748-1321(818)965-1006 <br /> ❑Mobile Labs,1(800)ENSECO-8 Page of <br /> PROJECT MANAGER <br /> CLIENT �A ALYSES - <br /> G 'Imm <br /> ADDRESS TELEPHO NUMBER(AREA CODE) <br /> 16a ?D al,4 u " #W,t <br /> CITY STA E ZIP CODE SITE CONTACT <br /> PROJECT NAME TELEPHONE NUMBER(AREA CODE) <br /> Lf gA 4� <br /> CONTRACT/PURCHASE ORDER/QUOTE NO. <br /> O � � SAMPLE TYPE NO.OF <br /> LAB/SAMPLE COW REMARKS <br /> �`h Sample Condition/ <br /> SAMPLE NO./IDENTIFICATION DATE TIME NUMBER LIQ. AIR SOLID TAINERS REMARKS <br /> -30 13I(O <br /> 3 1 a /3zd Z' <br /> 1330)121 <br /> 7 <br /> DO THE SAMPLE(S)POSE ANY POTENTIAL HAZARD(S)?IF YES,PLEASE EXPLAIN <br /> PLERS SIGNATURE) REL OUISHED BY(SIGNATURE) RELINQUISHED BY(SIGNATURE) DATE TIME The delivery of samples and the signature on this chain of <br /> custody form constitutes authorization to perform the analy- <br /> RECEIVE Y SIGNATURE) DA TIME RECEIVED BY(SIGNATURE) DATE TIME ses specified above under the Enseco Terms and Conditions, <br /> C l unless a contract or purchase order has been executed and <br /> v is sited above. <br /> RECEIVED F ORY BY DATE TIME DATE TIME SAMPLE DESPOSITION: <br /> RECEIVED , ACCEPTED <br /> 1.Storage time requested: days <br /> METHOD OF SHIPMENT (Samples will be stored for thirty(30) days without additional <br /> charge; thereafter storage charges will be billed at the pub- <br /> SPECIAL INSTRUCTIONS lished rates.) <br /> 2. Sample to be returned to client: ❑Yes ❑No (Enseco will <br /> dispose of unreturned samples for a charge of $15.00. Dis- <br /> posal will be by incineration wherever possible; otherwise, as <br /> appropriate, according to legal requirements.) <br /> DISTRIBUTION:WHITE-With Report;CANARY-To ENSECO;PINK-To Courier;GOLDENROD-To Sample Control <br />