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r <br /> <br />CHAIN OF CUSTODY RECORD <br />0 2979 East Center Street Conneaut, OH 44030 <br />0 1101 Howard Drive Deer P <br />k <br />TX 77536 <br />GS North America Inc Tel: (440) 224-2261 Fax: (440) 224-2808 <br /> ar <br />, <br />. Tel: (281) 930-1919 Fax: (281) 479-4969 <br /> <br />0 1501-A East Patapsco Avenue Baltimore, MD 21226 Tel: (410) 355-1958 0 4665 Paris Street. Suite 8-200 Denver, CO 80239 <br />Fax: (410) 355-1965 O 2804 Hackathome Lane Gillette <br />WY 82716 Tel: (303) 373-4772 <br />Tel: (307) 682 <br />7917 Fax: (303) 373-4791 <br />F <br /> <br />0 P.O. Box 850 Sophia, WV 26921 Tel: (304) 255.0422 <br />0 216 Oxmoor Circle Birmingham, AL 35209 Tel: (205) 942-3120 , <br />Fax: (304) 255-0417 0 Route 2. Box 162A Middlesboro, KY40965 <br />Fax: (205) 942 <br />0914 0 1555 - <br />Tel: (606) 248-4205 ax. (307) 682-7051 <br />Fax: (606) 248-0044 <br /> <br />0 5793 MacCorkle Avenue SE Charleston, WV 25304 Tel: (304) 925-0031 - <br />0 N. Lombard - Terminal 5 Portland, OR 97203 <br />Fax: (304) 925-8877 0 16130 Van Drunen Rnarr c-a u.,n. .r It Tel: (503) 285-5905 Fax: (503) 285.5086 <br />_--. ___ _ _ _ _ <br />CLIENT: <br />?. t l= <br />JF_1zS <br />? _-- <br />SGS Ref rertce: <br />CONTACT: ^ <br />k-jr <br />?• PHONE NO:(q .,_1 <br /> <br />C N 1` ? " 0 ? PAGE <br />?? <br /> <br />PROJECT: <br />SITE/PWSID#: G <br />NO <br />SATMPEE Presenaflves <br />Used <br />REPORTS TO: •`-? {. <br />Ftiy <br /> <br /> <br />AX NO.:( <br />) C <br />O <br /> <br />N <br />T <br />C= <br />COMP r`nai` <br />Required <br /> <br />3 /Y+/1? <br />C-1 <br />INVOICE TO: 6A To Dy <br />l <br /> <br />Z QUOTE #: <br /> <br />P.O. NUMBER: I A <br /> <br />N <br />E GRAB <br />. <br /> <br /> <br />LAB NO, <br /> <br />SAMPLE IDENTIFICATION <br />007 <br /> <br />DATE <br /> <br />?. f s?o <br /> <br />TIME <br /> <br />t I (5" <br /> <br />MATRIX <br />e. <br />W <br />R <br />S <br /> <br />Z <br /> <br /> <br />G <br />?. <br />r? ?T <br />V <br />V <br /> <br /> <br />EMARKS <br /> D ( q,?5 (•?yp g w 2 ? <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />y <br /> 4 <br />Collected/Relinquish(1) <br />C) <br /> <br />Relinquished By: (2) Date <br /> <br />9-rS,t? <br />Date <br />?J p <br />`/??/a0 Time <br /> <br />Igo <br />Time <br />//,30 Received By: <br /> <br /> <br />Received By: <br /> <br />zU <br /> <br /> <br />t <br /> <br />.L.?Q.? Shipping Carrier: <br /> <br />Shipping Ticket No: <br />Special Deliverable Requirements: Samples Received Cold? (Circle) YES <br />?O <br />Temperature C:? <br />Chain of Custody Seal: (Circle) <br /> <br />INTA BROKEN ASSENT. <br />Relinquished By: (3) Date Time Recelve-d By: Requested Tumaround Time and Special Instructions: <br />4 <br />Relinquished By: (4) Date Time Received By: