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SG CHAIN OF CUSTODY RECORD ? 2979 East Center Street Conneaut, OH 44030 Tel: (440) 224-2261 Fax: (440) 224-2808 <br />SGS North /America Inc. ? 1101 Howard Drive Deer Park, TX 77536 Tel: (281) 930-1919 Fax: (281) 479-4969 <br />? 4665 Paris Street, Suite B-200 Denver, CO 80239 Tel: (303) 373-4772 Fax: (303) 373-4791 <br />? 1501-A East Patapsco Avenue Baltimore, MD 21226 Tel: (410) 355-1958 Fax: (410) 355-1965 ? 2804 Hackathorne Lane Gillette, WY 82716 Tel: (307) 682-7917 Fax: (307) 682-7951 <br />? P.O. Box 850 Sophia, WV 25921 Tel: (304) 255-0422 Fax: (304) 255-0417 ? Route 2, Box 162A Middlesboro, KY 40965 Tel: (606) 248-4205 Fax: (606) 248-0044 <br />? 216 Oxmoor Circle Birmingham, AL 35209 Tel: (205) 942-3120 Fax: (205) 942-0914 ? 15550 N. Lombard - Terminal 5 Portland, OR 97203 Tel: (503) 285-5905 Fax: (503) 285-5086 <br />? 5793 MacCorkle Avenue SE Charleston, WV 25304 Tel: (304) 925-6631 Fax: (304) 925-8877 ? 16130 Van Drunen Road South Holland, IL 60473 Tel: (708) 331-2900 Fax: (708) 333-3060 <br /> <br />1 <br />CLIENT: tw? <br />vLItS <br />SGS R <br />nce: <br /> <br />L <br /> <br /> <br />CONTACT. PHONE NO:( <br />d p 0 T <br /> <br />l (,! <br />(?-Oso- <br />PAGE OF <br />_ <br />17 <br />0 <br />C N D `i L P <br />ti <br /> <br />PROJECT: SITE/PWSID# : <br />o <br />SAMPLE <br />TYPE <br />PE reserva <br />ves <br />Used <br /> Analysis <br />REPORTS T0: i FILY <br /> <br />FAX NO.:( ) O <br /> <br />T C- <br />COMP Required <br />3 <br />111 <br />INVOICE TO: QUOTE #: <br />2 S Lt, t.s P.O. NUMBER: 4 <br />R GRAB ?r 1 <br />LAB NO. SAMPLE IDENTIFICATION DATE TIME MATRIX S C/ <br />REMARKS <br /> 007 c? <br />(• 1 S,D ( ( ($- S vi -7- Cs '? <br /> oi( q.?S" ?Lzo sw 2 C? <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />5 4 <br /> <br />Collected/Relinquish (1) <br />C) <br />Date <br /> <br />1. (5. t8 <br />Time <br /> <br />Z U <br />Received By: <br />Shipping Carrier: <br /> <br />Shipping Ticket No: ?"',,? <br />Samples Received Cold? (Circle) YES - <br />O <br />Temperature C: <br />Relinquished By: (2) Date Time Received By: / <br />i ."l <br />I a' ILI Special Deliverable Requirements: Chain of Custody Seal: (Circle) <br /> <br />INTA BROKEN ABSENT <br />Relinquished By: (3) Date Time Received By: Requested Turnaround Time and Special Instructions: <br />r. <br />Relinquished By: (4) Date Time Received By: <br />Srti rr)r. RP„ 0/n7