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i~+~,e <br />CORE LABORATORIES, INC. <br />No. 48319 <br />CHAIN OF CUSTODY RECORD <br />~` '' "CUSTOMER INFORMATION '~ °' <br />COMPANY ~ T` - / ~ / <br />/V <br />L PROTECT Wl1EMUMBER: (Y <br />O <br />~ V <br />~ d / <br />SEND REPORT TO: ~~ <br />'/ BILLING INFORMATION ~ <br />~ <br />ADDRESS: <br />~j0 BILL TO `~ <br />J <br />L S A /S2 ADDRESS ~ \ <br />LAB JOB NO. <br /> I\ <br />~ 33 $ <br />PHONE' ~/ ~ 6 7a ~a exT iS" PHONE /~ ~ ` <br />FAX. ~ 9 6 7~ ~ .3 ~6 3 FAx: PO NO.. <br />.sp~AVLe' " "`"° <br />yy, <br />smrLE,lo. sAnsLe Dlsalrnaly - Q REMARKS:/sPR~CA (~ S <br /> 6 / O S B/~1rr0 .~ ~~~pS 96 0900 TPR STC / Rid ~Ye~ °~ o;ss a+r .!s <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />SAMPLER ./rO $FBPYENf MED100: ~PIJ AIRBILL NO.: 2 /)/IG~I SptJ <br />I b <br />REQUIRED TURNAROUND:' ~ ~ SAME DAY ~ ~ 2d HOURS ~ 18HWR5 ~ 172110URS ~ SDAYS r~ fODAYS I-I ROUTINE OTHER <br />I. (iEUNnU6FIED Y: DATE 2~ . ~ 2, " ~ ." DATE LWDUI BY: DATE <br />SIGNATURE /,t/p,~'/..~ <br />/~~1C SICiiATURE: SIGNATURE <br />PR9fTE EI P9N . <br />n/ .C <br />1. RECEIVED BY:. - ~P <br />SI TIM <br />o <br />DA <br />~~i <br />f0 PRQiIED NMIEICOIIPANY: <br /> <br />,y." . ~: <br />SIGNATURE: TIME <br /> <br />DATE PRINTED NAMF/CpAPANY: <br /> <br />~ <br />SIGNATURE: TIME <br /> <br />DATE <br />PRINT AMFICOMP Y' <br />!FC ~ RE T~F.,~r <br />(Jf.J~ PfWTED NAYEJCOYPANY TIME PRINTED NAMEICOMPANY: TIME <br />RUSH TURNAROUND IMY REWIRE SURCHMGE <br />^ ~ <br />Aw9.im, 61H.rnm 6 <br />A.r.r. lBw..r1. coler.e. <br />1190 E. Gene Aun, Wer ~ 10107 E. Bel Nnv O~ive <br />Amhnm, Glilprnu 91905 / <br />Aurprl. GOIpmEp 90011 <br />111119]1 1091 17071191"I J90 <br />IB001 .011617 190019111617 <br />^ Ctge, t,e•^ ^ Cewe Crim. TOn <br />170 Wet lv Shen 1777 Npnh hAm It1enE Drine <br />Caps, tl,pmi:q 016TH Gqut Chriai, Teut )8109 <br />0011175 9/11 191111p 7617 <br />00016-060D6 (90015Y-0179 <br />^ Nwew, Tns ^ ln6e Chlrln, Lwirinw <br />9110 Npelry Op1E ]619 9pht Pe6w„ <br />Hpunpn, Tenn 7/079 Sulphur. lpu:tune 106fi1 <br />(11]19179116 17181997J916 <br />190011 N"1617 19001199 7916 <br />^ Lenp 9esA, Cn01,mu <br />7100 Cheny Annue <br />fang Both. ULlomm 90901 <br />17101595-0001 <br />1900191/ d.]] <br />ORIGINAL <br />