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I 'Rik <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#'29M-IL-01- SA <br /> �� Purchase Order# Requested Analytical Method# THIS AREA FOR LAB USE ONLY <br /> w -IL-0 I- SA Lab# Page of <br /> Project Name T <br /> /' � � _M /�_ ) o p <br /> "D �C A Lab PM Custody Review <br /> Com any Name Lt- <br /> # <br /> C- 0 <br /> Project Manager or Contact&Phone# Report Copy to: F , j Log In LIMS Verification <br /> ot <br /> N <br /> Requested Completion Date: Site ID Sample Disposal: A C'J 1 pH Custody Seals Y N <br /> r ,ecp a Return <br /> 04// t�� V �Iv ❑ E Preservative Ice Y N <br /> ' b <br /> Type Matrix Rs QC Level 1 2 3 Other <br /> Sampling C G w S A <br /> M A T o R CLIENT SAMPLE ID LAB Cooler Temperature <br /> P B E L (9 CHARACTERS) QC <br /> Date Time R Alternate Description Lab ID <br /> rs I; 5 0 S a C - L L Z SSS SA, <br /> 30 1� <br /> c6:4+5 _ 0 L <br /> Rell quashed By Date/Time Received B Empty Bottles <br /> � p Y P Y Date/Time <br /> �✓�[ U S <br /> Sampled d Title (Pia-WOrn print na ate/Time Relinquished By (Please sign and print name) Date/Time <br /> Q <br /> Received By PI n e d p e) Date,4fime Relinquished By (Please sign and print name) DatelTime <br /> Received By ease sign and print name) Date/Tirne Shipped Via Shipping# <br /> UPS Fed-Ex Other <br /> Special Instructions: <br /> Q(3S[Out c< goS"' C 8r L - "^(= p A S <br /> Instructions and Agreement Provisions on Reverse Side DISTRIBUTION:Or/glnal- LAB, Yellow- LAB, Pink-Client <br /> REV 12/01 LAB FORM 340 <br />