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FEDERATED INSURANCE <br /> )aces P.O. Box 586, Citrus Heights, CA 95611 "� n 1 2 !-1 <br /> tNcowvanratfo CHAIN OF CUSTODY <br /> THF ASSU AANC I Of QUA tlt1 <br /> 10j Novato, CA, I 1 Digital Drive, 94949 <br /> Phone (415) 881-6100 Fax (415) 883-2673 <br /> onsultant's Name �'� 4�`S 1 I f f 1_ Name of Insured trorre Page,L of <br /> 7 /'Y��' ' +1' r, t v j ti, <br /> ddress IL'`_�t� �ttF1CI)Y 4 Pit, ' -,I- VILJ-t , I� 'il ��^ I'LdLralLd Sue. Lmation n,'2/J' c , r/f <br /> _ -- - - <br /> oject Contact l.AIMI (_1111_1 .L 1 }}13 I_ Phone# r��",_ 71/x' Fax # 'f' 'C) Federated Contact Gf,'IL <br /> irn led b nut) n 1 E �1tE + t j j - Sam let's St nd[ure PhonL # �'C -Jc'�`r'�(�f C Fax #tltl"} I�°{ SIG <br /> upment Method Consultant ProJLLt # t��.1 ', Kdt rats d Claim # Z <br /> iT 1:124 hr El48 hr ❑ 72 hr R Standard(10 day) ANALYSIS REQUIRED Santl,lL Cunduiun is ReLLned <br /> TLmpe,raturL"C <br /> xx Coo1Lr # <br /> W N Inbound Seal Yes No <br /> ct_a Outbound Seel 1(,% No <br /> ample Description Collection Matrix Prsv #of PACE p <br /> Date/Tune -4hwV a r Cunt Sample/! xQ Z¢ COh1h1ENT5 <br /> f-wI L I I I I I I U <br /> 0 2- <br /> ReL tushed by/Affiliation Date I Time Accepted by/All'iliation Date Timi. Addition d CoinmLnts <br /> �Ce l�s os - dR F 17 0(- <br />