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s . : a i i V 1 ♦rte t7 U�/ <br /> TRANSPORTATION, INC. Chain of <br /> Custody <br /> 3250A DUTTON AVENUE <br /> SANTA ROSA,CA 95407 <br /> Date: `�10�3��9 Page Of <br /> - <br /> Client: o ori Contact Tel. Fax; <br /> Address: Ci n f <br /> 73�C po- f-fae L� '7'� Lir. Lc�'ro�3� State: Zip Code: <br /> Project Name, ,, 1l <br /> W114- eo 1- Sample Disposition: Date: <br /> Project Manager: 3 I <br /> Sampler(s) Signature: R�K <br /> Due Date XRegular ❑Rush Da <br /> Approved By: <br /> Lab Date Time No.of <br /> Sample Description ID Collected Matrix Containers <br /> An Requested <br /> or <br /> Sample Conditions: Seal ❑Intact ❑Broken ❑ None;Temperature ❑Cold; ❑ oo ; Other <br /> Relinquished by {Signature} Received by (Signatur <br /> G Date/Time l <br /> Relinquished by (Signature) Received by (Signature) <br /> Date/time <br /> Relinquished by(Signature) Received by (Signature) <br /> Da#efrime <br /> Relinquished by(Signature) Received by (Signature) Da#ef rime <br /> SPECIAL INSTRUCTIONS <br /> 1r j!l ff J <br /> G 'I"�'LC�i, i'C'S 0�T, LC, , d t�fti+r' �-)✓l r^•rt 5!j C•7 i''ar�S ,� e-o <br /> WHITE COPY-Client YELOW COPY-Labortory PINK COPY-Courter SLUE COPY-Fue <br />