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SMITII-EMi�RY COMPANY O Z -1 � � CHAIN OF CUSTODY AND <br /> Thr bill Senae lndt pendent Testing l,aborarory biahhshed 1944 N PSIS REQUEST <br /> 781 East Washington Boulevard Los Angeles,California 90021 0 (213)749 3411 & Fax 1213)745 6372 DATE ' C�' PAGE��OF O <br /> P O Box 880550 Hunters Point Shipyard Bldg 114 San Frnn Mco,California 94 f;88 ,,• (415)330 3000 0 Fax (415)822 5864 Ll a IT <br /> 5427 East La Palma Avenue a Anaheim California 92807 rt • (714)693 1026 • Fax (714)693 1034 FILE NO IAB NO <br /> CLIENT NAME TQ C <br /> ANALYSES REQUESTED REMARKS A+R 6 I l tt <br /> PROJECT NAME PROJECT NO , 71 PO NO <br /> ADDRESS <br /> PROJECT MANAGER /CHS L cc)S PHONE# FAX# N '� I° F <br /> SAMPLER NAME J l_E"1 U & >��41 <br /> (Printed) I rel <br /> TAT(Analytical Turn Around Time( 0-Same Day, 1 -24 Hour, 2-48 Hour, (Etc) < 1 t <br /> CONTAINER TYPES B=Brass,G-Glass,P=Plastic,V=Voa Vial,0-Other '.2 �t W <br /> MATRIX —ENT— 00 SAMPLE CONDITI0N1 <br /> SAMPLE DATE TIME SAMPLE DESCRIPTION COMMENTS' <br /> NO SAMPLED SAMPLED WATER sass uocse OTHER TAT a rrvE <br /> 3 � � � 16•. 5 � � v � I <br /> Q%v L4 Ile <br /> {lJ s - I 1 �1`r ��" f e► �i L} rl e� •- <br /> T3L1�Ir G17 ( <br /> 1 <br /> 1 ' <br /> Relinquished 9y(Sgnature and Printed Name) erved By(S,gnat and Prated Namel Date Time SAMPLE DISPOSITION t <br /> OJL.. % I/A l i`� 11 `�5 1 Samples returned to Ghent? YES NO <br /> RehnquisW By (Signature and Printed Name) Received By(S,gnaiure and Pnnted Name) Date Time <br /> 2 Samples will not be stored over 30 days,unless <br /> additional storage time is requested <br /> Relxquished By[Signature and Printed Name) Fieceived By(Signature and Printed Namel Date Time <br /> 3 Storage time requested days <br /> , <br /> SPECIAL INSTRUCTIONS By Date — <br /> + DISTRIBUTION WHITE,YELLO VK TO SEGO—GOLD TO CLIENT <br />