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Laboratories,Inc. <br /> Chain of Custody Form <br /> IZ� Project#: Page of <br /> : <br /> Attn: 41b" "#J6 Project Name: aNF�r-y Comments: <br /> Street Address: Q Global ID#: gpp a� k�-f <br /> Ci Zi State, P)-34.• KG P/ Sampler(s): 43 <br /> Phone <br /> CC-13VIII Fax:QZ-737-N <br /> Sample Matrix 11 there any tests:vvith balding times less than <br /> or e0al to 48 hours? <br /> Email Address:!—I�SkAA�— '6 7A A <br /> El yo JS No <br /> Work OrderStandard Turr�around=10 work days <br /> a Notes <br /> Other <br /> kq <:%Ij57 <br /> U3 <br /> 111 0 <br /> 50 <br /> DE <br /> A 116 <br /> CHK4W I-)Q ON <br /> .. . ........ <br /> '9LUBI-Ou"'I" E-3 <br /> ❑ <br /> Sample Disposal Special Reporting <br /> Same as above EDF Required? QC EDF Raw Data <br /> Pt.M to Client Disposal by lab ❑ Archive:IMonths <br /> Client <br /> 1. ReVuishedinquished FK Date Time 1. Received By Date Time Yes No � jjq(%) Q4 Lby* <br /> lt}J pie? <br /> 72- ,Av�,)a Poz)j <br /> Address: IDate Time We KV, B%3, Date �Tinle <br /> 2. Y <br /> zi ?:55K; Send Copy to State of <br /> City: teCA P— CA?(EDT) <br /> S tot I <br /> R <br /> 3. Relinquished By 3. Received By Dale Tie <br /> Yes No Date Received <br /> 'd By <br /> IPO#: <br /> BC Laboratories,Inc.—4100 Atlas Ct.—Bakersfield, CA 93308—661.327.4911—Fax: 661.327.1918—www.bclabs.com <br />