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Excelchetis <br />50 Giuseppe Court, Suite 3 <br />. <br />Rosevilre, CA 95678 <br />CHAIN -OF -CUSTODY RECORD AND ANALYSI S REQUEST <br />Environmentat'Gbs <br />Ph* 915-773-3664 Fx: 916-773-4784 <br />Project Managen. <br />Phone #: <br />Electronic Data Deliverables Request: <br />-2-4k P <br />ANALYSIS <br />REQUEST <br />V111.S(4 <br />rvyV of <br />Wet - <br />Ln <br />TOW <br />Project Location: Sampler Signature: <br />Sca <br />—M <br />ICY, <br />a <br />Method <br />Sampling Container Matrix <br />Preserved <br />ID Date Time <br />d <br />U. <br />0 <br />Z5 w <br />CS <br />Relinquished by-. <br />nate <br />Time Received by: <br />Remarks/Condition of Sample: <br />Relinquished by.- Date Time Received by: <br />Relinquished by: <br />Date - <br />Time Received by Laboratory: <br />Bill To: <br />