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C?7~l', <br />CORE LABORATORIES, INC. <br />No. 48564 <br />CHAIN OF CUSTODY RECORD <br />CUSTOMER INFORMATION <br />' -~, r'~ P ~PAQJ, ~T,INFO(jMA,TION % ~ h : ~ <br />_ .r ~ <br />. n" <br />O^~ ~ <br />COMPANY <br />r~cu- 1.u.•~s PROJECT NAMEMUMBER: yN, v <br />~ ~ ~ <br />c ~ <br /> <br />SEND REPORT i0' ~1 ~ <br />l <br />BILLING INFORMATION o <br />, <br />v <br />ADDRESS <br />T <br />_ , ~. 0 V BILL TO ~r e <br /> <br />y <br />D LSo7 <br />_ J ADDRESS: "L~' <br />~L ~ y~~a <br />~/ LAB JOB NO. <br />~ <br /> ~ ~ , <br />0 <br />PHONE ~ I ~ I~ <br />FA% ~ i~ ~e7~-3343 / <br />1 PHONE <br />FAX PO NO: ~~ <br />r ~" a O y <br />~~ F' ~ (~ <br />• <br />SM9'LE N]J SMILE DESCNIPTION '~'~~"$ ' ~` LE <br />~. v SMILE <br />~ a PLAINER-T'P ~~ <br />~ ~~~ ~4 M ' ] <br />g ~ <br />~ ~.. <br />y~. fY~~RKSr/~FIE~,A~TJONS <br /> <br /> 8 a n s- <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />$AMPL CZ _ L SHIPMENT METHOD AIRBILL N0. <br />REQUIRED TURNAROUND' ~ SAME DAV J 2a HOURS [~ aB HOURS Cl 71 HOURS I 5 DAYS I f 10 DAYS U ROUTINE OTHER <br />L RELINOUISHEiD BY. ` ' DAT ELINCUI$ ED BY: - '' ~ DATE YRELIA ~ ISRED 0Y: DATE <br />AT R ~ <br />~ GL~ ~ ~ .SIGNATURE: ~ ~ SIGNATURE' <br />PRI ,tj(~MEfp~P NY <br />1 - T <br />~~~ PRINTED NAMFJCOMPANV: TIME PRINTED NAMEILOMPANY TIME <br />1 RECEIVE B5` - DA .RECEIVED BY:. DATE 0. RELEIVEO'BY: DATE <br />GNATU .' 3 SIGNATURE: SIGNATURE <br />PRI TED NA .COMPANY' TIME PRINTED NAME/COMPANY TIME PRINTED NAMFICOMPANV TIME <br />RUSH TURNAROUND MAY REQUIRE SURCHAR <br />^Ambim, GLlo~mn Aurora lOmrnl, COlenao <br />1150E Gene Au~rv Wry 10103 E. Bahony Ou.e <br />Amha n, Gldamq 91805 Avon. L0101,a0 BOON <br />111/1371 JO91 130311511160 <br />18001 101 1617 16001911 1617 <br />^ boor, WYOmm, ^ Corpm Chrini, Tm <br />QO Wat In 61nn 1777 North Poare hhna Dun <br />G,pa, WYpminp 67fA1 [prpn Lnrnti,Tnu 761DB <br />170717755711 15171769 7677 <br />16001666-0706 IBOOI Sa6-0778 <br />^ Heunen, Tm ^ Lnb Lhaln, Lounum <br />8710 MaJry Pooa 7619 6o9hr Pa1w1y <br />Hpunpn, Lou 17075 Sulphur, Lnmrum 10667 <br />17131917~977fi 17161667 A976 <br />160011317617 16001759 J97fi <br />^ Lpnp 4ah, Ctlilpnu <br />3100 Chary Avenue <br />lan9 6ooh. Gutornb 90801 <br />171015958101 <br />16001611.].]] <br />ORIGINAL <br />