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UAir Sample Transportation Notice <br /> Relinquishing signature on this document Indicates that sample is being shipped In compliance with 160 BLUE RAVINE ROAD,SUITE B <br /> g FOLSOM,CA 95630-4719 <br /> TORI wS LTD. all applicable local,Stelae Federal,national,and lith respect <br /> t Jews,of regulations s end ordinances o <br /> any kind.Air Toxics Limited assumes no liability with respect to the collection,handling or shipping (916)965-1000 FAX(916)965-1020 <br /> of these samples. Relinquishing signature also indicates agreement to hold harmless, defend, ) <br /> CHAIN-OF-CUSTODY RECORD and Indemnify Alt Toxics Limited against any claim,demand,or action,of any kind, related to the Page I of <br /> collection,handling,or shipping of samples. D.O.T.Hotline(800)467-4922 <br /> Turn Around Lab use only <br /> Project Manager rD/ • Pro)ectlnfo: Time: Pressurized by: <br /> Collected by:(Print and sign)TIM—IrgrrY7 5 P.O.# 3 1Normal 6 19641 V Nl <br /> �]����� ':..Date: <br /> Company Aci Emaii ncla rva /(tQlf ❑ Rush <br /> �� ADZ/ Projects iia/lf/cS�(o /ylir% Pressurization Gas, <br /> Address/0�/dW/Azn '.FA Clty state_zip <br /> Phone 9/41 yC.� Fax 9/b• / bz/U/ Project Name J'0(I�1lJ S/DI Ziil spe,;y Nz He <br /> Date Time Canister Pre sure/Vacuum <br /> Lab I.D. Field Sample I.D. (Location) Can# of Collection of Collection Analyses Requested Initial Final Receipt FI <br /> TPf1 Tick, NTsI <br /> zoio 045 5 sTm I74 >ti — 3U <br /> Wt,Prez N�Pm Tc- <br /> 2v IZ30 w. v4a o rr -30+ 5 <br /> X14 -2D 5102 Wso za,o �3t) iPr,',i w oH� 2 -5 <br /> 36 � � 11� u+/v �`I55 s�mvi o� [� � -3b •S <br /> 7eImqui,9,Kadby: <br /> qulshed b signature) ate�me v d b : signature) Date/Time Notes: <br /> y3 y <br /> (signature) Date�me Rece ved by:(signature) Date/Tlma <br /> Relinquished by:(signature) Date/Time Received by:(signature) DateRme <br /> A <br /> Lab Shipper Name Air Bill# Temp CC) Condition Custody Seals Int work Order It <br /> Use <br /> iJ 19 Yes No one <br /> Only <br /> Form 1293 rev.11 <br />