Laserfiche WebLink
\§� <br /> , C � 7w WORK 0ro <br /> kAlppha <br /> 4CHAIN OF CUSTODY RECORD <br /> ��'� �y a�Analytical Laboratories Inc • 860 Waugh .ane,H-1,Ukiah,CA 95482 • (707)468-0401 • FAX(707)468-5267 BATE PAGE OF <br /> :LIENT S NAM�j �1 - P 0 CT +N <br /> MANAGE <br /> R <br /> L P-UCS c� e Cc-� r C�ht L�EJ nx� 2 <br /> p j SAMPLE CONDITION ON <br /> J T]t (` { � RECEIPT <br /> iTREET ADDRESS / CITY STATE r,1P [Hp E NUMBE C Ln n � 5 �_ <br /> o`er E <br /> H COLDACED? <br /> PROJECT NAME FAX NUMBER 1 N <br /> CONTRACT/PURCHASE ORDER/QUOTE NUMBER SITE CONTACT �d BUBBLES OR AIR SPACE? <br /> 1 <br /> 4 <br /> SIGNATURE OF PERSON AUTHORIZING WORK SAMPLED BY r )h WERE SAMPLES PRESERVED? <br /> JNDER TERMS STATED ON REVERSE SIDE OF <br /> THIS FORM Q <br /> 1 <br /> ,"SAMPLE NUMBERADENTIFICATION DATE TIME LAB SAMPLE NUM <br /> • • • <br /> C-0—0� I <br /> /1�l C/P���i�f/ E•UcJ.+�cyP.r� /e,c� ,v I <br /> RELINQWSHED (:�ed4 ' <br /> LSC ECEIVED BY DATE TIME •• - • • <br />(SIGNATURE � � (SIGNATURE) <br /> RELINQUISHED BY RECEIVED BY DATt TIME <br />(SIGNATURE) (SIGNATURE) / ,�, h9ilfa,� " �A <br /> RELINQUISHED BY RECEIVED FOR SAMPLE CONTROL OFFICER <br />(SIGNATURE) LABORATORY <br /> 1 <br /> METHOD OF SHIPMENT AUTHORIZED BY SAMPLE DESPOSITION <br /> 1 STORAGE TIME REQUESTED DAYS <br /> SPECIAL 1NSTRL)CT10N5 (SAMPLES WILL BE STORED FOR 30 DAYS WITHOUT ADDITIONAL CHARGES <br /> 1 THEREAFTER STORAGE CHARGES WILL BE BILLED AT THE PUBLISHED RATES) <br /> 2 SAMPLE TO BE RETURNED TO CLIENTS ❑YES ❑NO <br /> DRIVING TIME SITE TIME AL TIME HAZARDOUS MATERIALS ARE THE PROPERTY OF THE CLIENT THE CLIENT IS <br /> �Cz�i / r RESPONSIBLE FOR PROPER DISPOSAL OF HAZARDOUS WASTES CLIENTS NOT <br /> PICKING UP HAZARDOUS WASTES MAY BE ASSESSED AN APPROPRIATE FEE <br />