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to 11 It <br /> Applied Sciences Lab 155 Grand Avenue,Suite 1000 <br /> CHAIN OF CUSTODY RECORD Oakland,CA 94612 <br /> AND AGREEMENT TO PERFORM SERVICES (510)251.2426 <br /> COC# <br /> Project# �{Q Purchase Order# Requested Analytical Method# THIS AREA FOR LAB USE ONLY <br /> 2 l 94—.01 ( A Lab# Page of <br /> Pract Name T <br /> F f6 Z-A—( "Au-P A :�& d� J <br /> T T <br /> A �J � Lab PM Custody Review <br /> Company Name a <br /> kJ4 o o <br /> Project Manager or Contact&Phone# Report Copy to: F I Log In LIMS Verification <br /> D I AA,F c �� s <br /> N C <br /> Requested Completion Date: Site ID Sample Disposal: T I� I pH Custody Seals Y N <br /> A <br /> ZA -��/�,,� olsp a Return <br /> YT l�CP O E Preservative rice Y N <br /> Matrix <br /> R <br /> Type s QC Level 1 2 3 Other <br /> Sampling C G w S A <br /> M A T I R CLIENT SAMPLE ID LAB Cooler Temperature <br /> P B E L (9 CHARACTERS) QC <br /> Date Time R Alternate Description Lab ID <br /> •1 0$ 0 1 - 10 X a G AZ <br /> vyox 9106 2 — 12 1X, X <br /> p S I ,Y/ XXX <br /> t. <br /> t, 12a5 S WS <br /> t- <br /> (4" I f - }C <br /> S - CA I 11 t/ <br /> 135 i I <br /> A <br /> Reil quished By —Betefftme Received AMPW4"U" Date/Time <br /> /k�ff 776 l <br /> ampled By and Title ease An. prnH Date/Time Relinquished By (Please sign and print name) DatelTlme <br /> eceived By (Pt a gn and grin name) Date/Time Relinquished By (Please sign and print name) Date(Tlme <br /> Received By ( ase sign and print name) DatelTlme Shipped Via Shipping# <br /> UPS Fed-Ex Other <br /> Special Instructions: <br /> Instructions and Agreement Provisions on Reverse Side DISTRIBUTION:Original- LAB, Yellow- LAB,Pink-Client <br /> REV 12/01 LAB FORM 340 <br />