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�^1 d <br /> CHAIN OF CUSTODY RECORD <br /> -4MPLER (signature): <br /> Phone.' G' 1 r 4191-E Power an Road,Sacramento,CA ggg� <br /> ~ •F . (9'16)452-1901 <br /> Fremont LABORATORY:v Costa Masa •Sacramento <br /> SHIPPING INFOgMATIQN <br /> Shipper <br /> Address <br /> TUPNAROUNO TIMfcDate Sh}Pped <br /> Attention: �, J f✓1f ti Service Used <br /> r Alrbill No. <br /> Phone No. { G , ` tic-_7q Cooler No, <br /> Relinquished by:(s}gt-atur / <br /> Re fired by;(signatureal Date <br /> Time <br /> Received for laboratory by' <br /> I ��3�1�, le <br /> Sample <br /> a <br /> loAA pKy SHOULD SIGN UPON RECEIPT AND RETURN A COPY OF THIS FORM W <br /> LABORATORY RESULTS WITH THE <br /> Sample Site <br /> No. Date Anal Identification Analyses Sampled Requested Sample Condition <br /> � n _- �---- �� Uonn Receipt <br /> -------------- <br /> �- <br /> --------------- <br /> --�--•— ------- ----- <br /> - <br /> -�. <br /> ------------ <br /> --------------- <br /> 1� <br />