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i <br /> SMITH-EMERY COMPANY CHAIN OF CUSTODY AND <br /> The Fu11 Service Independent Testing laboratory Ertabbshed 1904 -ANALYSIS REQUEST <br /> 781 East Washington Boulevard • Los Angeles California 90021 • (213)749-3411 0 Fax (213)745 6372 DATE r r C' PAGE OF <br /> P O Box 880550 Bunter s Point Shipyard Bldg 114 a San Francisco California 94188 • (413)330-3000 0 Fax (415)822 5864 <br /> 5427 East La Palma Avenue • Anaheim California 92807 • (714)693 1026 • Fax (714)693 1034 FILE NO LAB NO <br /> CLIENT NAME T-H j Y V ` � C,& ANALYSES REQUESTED REMARKS ` <br /> PROJECT NAME PROJECT NO 7 J PO NO <br /> ADDRESS <br /> PROJECT MANAGER A4 I dV1A+L CoS f Y PHONE FAX# w <br /> _ co <br /> SAMPLER NAME E Q t:-t-N 1 V C>,-11 S M q-V o <br /> (Pnntedl (Si re) � X <br /> W <br /> AT(Analytical Tum Around Time) 0-Same Day, 1 =24 Hour, 2=48 Hour, (Etc) < m <br /> CONTAINER TYPES B=Brass,G=Glass,P=Plastic,V=Voa Vial,0-Other oCIJ <br /> SAMPLE DATE TIME MATRIX CONTAINER CO ra SAMPLE CONDITION/ <br /> NO SAMPLED SAMPLED SAMPLE DESCRIPTION WA'aa sow uo" OTHM TAT a WPE COMMENTS" <br /> AWG 3.9 11� 11.1 00 Z N X <br /> �1�1 V �I// 114 <br /> A/f ? V <br /> 13 `r 6 : <br /> Reuished By(Signature and Pnd e) + Received By(Signature and Printed Name) Dale Time SAMPLE DISPOSITION <br /> C G'gsm� nte � 1 Samples returned to client9 YES NO <br /> Reimqurshed By(Signature and PiintwrNFteced By{tgn re and Printed Name} ate Time <br /> c� r _ t" c j 4 j /�C 2 Samples will not be stored over 30 days,unless <br /> Relinquished By;Signature and Printed Name) Received By(Signature and Pri ted Name) Date Time additional storage time is requested <br /> BY <br /> Storage Ume requested days <br /> SPECIAL INSTRUCTIONS c^ i Date <br /> r DISTRIBUTION WHITE,YELLO> K TO SECO---GOLD TO CLIENT <br />