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!Tech <br />bo ■tories.Inc. <br />320 Tesconi Circle, Unit R <br />Santa Rosa, CA 95401 <br />CHAIN OF CUSTODY RECORD <br />Date Submitted �' Multi -Tech Sample No. a T <br />Client's Name L�Ci iGC �U/ <br />Address_, 3�C � . ,�Lot <br />Telephone <br />Sample Collected By <br />Client's Sample Identification �j�G ebd� ��% 7 _ <br />5A, ae4? 604L a;170 AF7c 445 Ailzaa <br />±Ld.,-: G 0 2- , e A 6, <br />Sample Allocation <br />1. <br />Name of organization <br />2. <br />Name of organization <br />3. <br />Name of organization <br />Chain of Possession <br />1. � - <br />Signature TitlgInclusive dAtes <br />i s e Ti3. tkk� / Inc usive d s <br />/ Signature Title Inclusive d5tes <br />I ` <br />Date released from Multi -Tech custody <br />