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_ Page__L of <br /> I <br /> r Chaf n ®T Custody ecoird -site Time: Temp: <br /> ?iro j ect Name " ' <br /> J [Sky <br /> f-site Time: Temp: <br /> 4:t_ 3? 13U/GIE C® Portfolio: Conditions: <br /> 3P Laboratory Contract Number: <br /> eteoroatE' )Requested Due Date(mm/dd/yy) -Y nd S logical Events: <br /> !-�� peed: Direction: <br /> Seed Tos JP/GEM <br /> EM Facility No.: ,f onsultant/Contractor: <br /> iLab Name: <br /> Facility Address: i,•o " ' <br /> �I.ab Address: � � ,.�fy ':.y ;t�.�..� ddress: %� �7 ..r r,�.rol=� i!• it <br /> ID No. !- r <br /> Site Lat/Long: <br /> _ -mail EDD: <br /> California Global ID#: „�i" �`Ir <br /> �` � ���e ,. � Consultant/Contractor Project No.: <br /> Blab PM: P/GEM PM Contact: �" --�-' t <br /> Consultant/Conractor Tele/Fax: <br /> Tele/Fax: <br /> Address: t ° Consultant/Contractor PM: f, <br /> Report Type QLevel: <br /> BP/GEM Accoountt Invoice to: Consultant/Contractor or BP/GEM (Circle one) <br /> No.: Tele/Fax: P/GEM Work Release No: <br /> Iab Bottle Order No: Matrix Preservatives Requested Analysis 7 <br /> R <br /> e Item Sample Description Time '2 a' w Laboratory No, of <br /> Point Lat/I on and <br /> No. n ami ry v o g <br /> Comments <br /> a O ¢ �� 1 .t <br /> zCn <br /> d .� <br /> 00 <br /> w <br /> 2 ' <br /> 3 <br /> j <br /> G s'V.41 <br /> f r tr»• <br /> 10 �� <br /> Sampler's Name: Relinquished By/Ai Watton ate hne ccepted By/Affdiation Date ime <br /> Sampler's Company: <br /> Shipment Date: <br /> Shipment Method: <br /> Shipment Tracking No: <br /> Special Instructions: <br /> 'Custody Seals In Place Yes No Temperature Blank Yes No Cooler 0 <br /> o er Temperature on Receipt FIC Trip Blank Yes Noy- <br /> CONUL AN ! NTRA TOR BP COC Rev.1 2/5102 <br /> __ I <br />