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LABORATORIES, INC. <br />R.Xm T. �� <br />Client: Project #: i fQ <br />Attn: t L I- L-0 PIE Z- Project Name: 30,aDo <br />Street Address: �, $ 5 . ii u�f./�j , <br />City, State, Zip: SA/.J ] - Sampler(s): rioTM <br />Phone: Fax: <br />Email: _ <br />er #: Z <br />Work Ord ' � <br />� <br />f) 1101 <br />a <br />\D <br />c� <br />A <br />Chain of Custody Form <br />Page of <br />Comments: <br />p 1 SSno t j e- <br />Sample Matrix Result Request -Surcharge <br />❑ ❑ <br />3 TD ❑ 5 Day" 2 Day" 1 Day" <br />2 1 Days) <br />— e 'o <br />a 3 Omer Notes <br />-it /U1 <br />--' $ to l <br />1101_13 <br />td <br />° <br />Client: <br />Same as above <br />EDF Required? <br />Geotracker <br />❑ Yes �:o <br />...... <br />Send Copy to <br />State of CA? (EDT) <br />El Yes )4No <br />Global ID <br />(Needed for EDF) <br />System # <br />(Needed for EDT) <br />Address: <br />1 Re q hed B Date Time 1. Re By Da Tim <br />p (0 1 17� 17 <br />City: _ State Zip <br />Attn: <br />2. linqui e D e Time 2. Receiv Date Time <br />/� -, � fir1 P/10//'7014 <br />P.O. #: <br />3. Relinquish y Date Time 3. Re iv D e Time <br />J /U `L7i` �U <br />BC Laboratories, Inc. — 4100 Atlas Ct. — Bakersfield, CA 93308 — 661.327.4911 — Fax: R61 397 1 Vb6labs.corn <br />0 0 0 <br />