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OMP MIL <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 <br /> C�# Purchase Order# Requested Analytical Method# THIS AREA FOR LAB USE ONLY <br /> q 94. O(• 5%a Lab# Page of <br /> Project Name 0 0 1 <br /> P64�il LA T-/ON A Lab PM Custody Review <br /> Company Name # J I <br /> 0 <br /> Project Manager or Contact&Phone# Report Copy to: F h Q ` Log In LIMS Verification <br /> N �-n cam. C CL <br /> Requested Completion Date: Site ID Sample Disposal: A CV �—i � �--� pH Custody Seals Y N <br /> /A Dlsp a Return I ! 111 <br /> ��f' [ 6 t�� �� l�P ❑ E Preservative Ice Y N <br /> R <br /> Type Matrix S QC Level 1 2 3 Other <br /> Sampling C G w S A <br /> R A O <br /> CLIENT SAMPLE ID LAB Cooler Tem erature <br /> �T� MP B E L R (9 CHARACTERS) QC p <br /> k4 ate Time R Alternate Description Lab ID <br /> 0 s1wIll1 O 5--S j <br /> 2 o7sa 0SwZ2 t 0 <br /> id-16 07'55 \,c 0 S 12- 3 -- 1 to 7 A u� <br /> oS 24 - I <br /> S it �INr S 2 6 7 <br /> 3 13-0 O B 27 <br /> 0 - p <br /> to (Sso <br /> Rellnqulshed By Date/Time Received By Empty Bottles Date/Time <br /> 04. — l6cyt <br /> ampl (PI s n and print name Date/Time Relinquished By (Please sign and print name) Date/Tlme <br /> ed B and Title <br /> ( o -0 <br /> Rec ed By P se sig m DatelTime Relinquished By (Please sign and print name) Date/Time <br /> Received By (Please sign arWprint name) Date/Time 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 />