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Centrum Analytical Laboratories, Inc. �~ Centrum .lob # A <br /> 290 TENNESSEE STREET— (909)798-9336•(800)798-9336 <br /> REDLANDFAX(909)793-1559 Chain of Custody Record <br /> S CA 92373 <br />- _ Page � of ' <br /> _ - //jA,,1'yses Requested <br /> Project No _ Probed Name <br /> .. `Z �C ���7 m o e Turn-around time <br /> _ a <br /> Prpled Mia-ger + Ione Fax d ❑ 24 Hr RUSH' <br /> irn_ <br /> _ t S� d 5 o o LO a , s ❑�Hr RUSH* <br /> In <br /> Client Name ddress a v : Normal TAT S <br /> (Cnmpeny) Q� p Unval thw�v� <br /> = w N i? sd9hnxQes ePPH <br /> 10- Date Time Sample Containers 0 tau. o o Remarks/ <br /> Centrum ID Sample 1D _ Site locatlotl <br /> -- _ (Lab use only) (As It should appear on repmi) sampled sampled matnx #and type V o0 'r' n p = Special Instructions <br /> - C7 eo c40 Q N J`� n Ci <br /> / OLK - t-12� 0r46 7'o� �J -L sf9dVOL 3 <br /> -4 2•to� 6143 �1 - 9 Wily "A-3 <br /> - — - - 2-ro Vi G-W LI s 000 VOR -3 <br /> - w- MY-4111,t il {x,41 Grw - 5evt 10017 VOA-3 <br /> - -- =� W-q y-y eta,q L't`Iy CAJ r-i err 100'r?) uo <br /> -7 <br /> eY,te 100voA- <br /> - -- -- w- MY-4_ ,to-t Ir,�y� Gr-�f - sever a sta o - <br /> W-? M -4 2`101 611 V-4f -- 2M l 00$78 CION- <br /> -- _ Mvo-t t"So -z se Vic 100,9v0Ar- <br /> 1(1 Pj,.L 161-41 :to (ei143 C-0 I serue (WIS Voq - <br /> ` -- ebmtw d by (Sa ss Date Tuna Relinquished by Data To he completed by laboratory personnel Sample Disposal <br /> Rec d Date Time Received by Data Time Samples chllled7xyes ❑No <br /> 13Client will pick up <br /> -- - - Custody seals? ❑Yes*0 <br /> Relinquished by Date Time <br /> T_he_deltvery of samples and the signature on this chain of custody form All sample containers Intact?*es d No d Retum to client <br /> constitutes authonzation to perform the analyses specified above under Recei t ry by a Time ❑Courter >WPS! ed Fac ❑Hand tented <br /> - - - the Terms and Conditions set forth on the back hereof Lab disposataea% <br /> Laboratory Notes Sample Locator No <br /> =--_ �9 3 <br /> White Copy Onpinal(Accompanies Samples) Yellow Copy Centrum Files Pink Copy-Client Copy <br />