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SMITH EMFPY COMPANY I CHAIN OF CUSTODY AND <br /> AeFull SenueIndependent Tis+mgLubonuory Fsruhlrshed 1904 .ANA—LYSIS REQUEST <br /> yi�4 -�- <br /> 781 East Washington Boulevard • Las Aogdes California 90021 • (213)749 3411 • Fax (211)745 6372 DATE T— ? PAGE / OF / <br /> P 0 Bax 880550 Hunter s Point Shipyard lildg 114 • Sin Francisco California 94188 • (4i 5)330 3000 • Fax (415)822 5864 <br /> 5427 East La Palma Avenue • Anahwin California 92807 • (714)693 1026 • Fax (714)693 1034 FILE NO ' LAB NO <br /> CLIENT NAME 7 ���r olL Cc, ANALYSES REQUESTED REMARKS <br /> PROJECT NAME T cc SS zl 17Z PROJECT NO /l rr*/JZ P 0 NO' <br /> r <br /> ADDRESS <br /> ❑ <br /> PROJECT MANAGER I'11("A trZ_ rO,516?ly PHONE LO)- 5�F76 FAX# w <br /> co <br /> SAMPLER NAME T ko S`!v �� ?� ` , o <br /> {Pruttedl (S+gnaturel <br /> ❑ x <br /> TAT(Analytical Turn Around Time) 0 s Same Ray, f =24 Hour, 2=48 Hour, (Etc) a m <br /> CONTAINER TYPES B=Brass,G-Glass,P=Plastic,V=Voa Vial,0=Other °Q—° �- <br /> CX11 CO <br /> SAMPLE DATE TIME MATRIX CONTAINER m SAMPLE CONDITION/ <br /> NO SAMPLED SAMPLED SAMPLE DESCRIPTIONWA7En TAT COMMENTS. <br /> SOft UDOE a7NFA / TYPE <br /> fly S /Z x n x x <br /> Iq / / W-_:� o V X, x <br /> x x <br /> Relinquished By[Signature and Pnnied Name) Recf�°edBy{Sigaature,�od Panted Name)' t Date Time SAMPLE DISPOSITION <br /> 7�)1 I'�i r�prin <br /> Aet Samples returned to chem? YES <br /> +inquished By(Signahue and ted Namet Received By(S�gnature and Primed Name) Date Time <br /> ' 2 Samples will not be stored over 30 days,unless <br /> Relinquished By(Signature and Printed Name) Received By(Signature and Panted Namel Date Tura additional storage time is requested <br /> 3 <br /> PECIAL INSTRUCTIONS Storage time requested days <br /> S <br /> 1By Date <br /> DISTRIBUTION WHITE YEI f PINK TO SECO—GOLD TO CLIENT <br />