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CHAIN OF CUSTODY RECORD <br />SGS North America Inc. <br />? 1501-A East Patapsco Avenue Baltimore, MD 21226 Tel: (410) 355-1958 Fax: (410) 355-1965 <br />? P.O. Box 850 Sophia, WV 25921 Tel: (304) 255-0422 Fax: (304) 255-0417 <br />? 216 Oxmoor Circle Birmingham, AL 35209 Tel: (205) 942-3120 Fax: (205) 942-0914 <br />? 5793 MacCorkle Avenue SE Charleston, WV 25304 Tel: (304) 925-6631 Fax: (304) 925-8877 <br />1 'r <br />? 2979 East Center Street <br />? 1101 Howard Drive <br />? 4665 Paris Street, Suite B-200 <br />? 2804 Hackathorne Lane <br />? Route 2, Box 162A <br />? 15550 N. Lombard - Terminal 5 <br />? 16130 Van Drunen Road <br />Conneaut, OH 44030 <br />Deer Park, TX 77536 <br />Denver, CO 80239 <br />Gillette, WY 82716 <br />Middlesboro, KY 40965 <br />Portland, OR 97203 <br />South Holland, IL 60473 <br />Tel: (440) 224-2261 Fax: (440) 224.2808 <br />Tel: (281) 930-1919 Fax: (281) 479-4969 <br />Tel: (303) 373-4772 Fax: (303) 373-4791 <br />Tel: (307) 682-7917 Fax: (307) 682-7951 <br />Tel: (606) 248-4205 Fax: (606) 248-0044 <br />Tel: (503) 285-5905 Fax: (503) 285-5086 <br />Tel: (708) 331-2900 Fax: (708) 333-3060 <br />CLIENT: l?lZ vL1t5 SGS Ref rence: <br />PHONE NO:( <br /> <br />_ _1 2 C? ?? <br />CONTACT: ? V%kA <br />]? O ?6 `? P?W P <br /> <br />/ <br />O ? 9 <br />PAGEOFI_ <br />, <br />11 <br /> <br />PROJECT: SITE/PWSID# : <br />N o <br />SAMPLE <br />TYPE Preservatives <br />Used <br /> A <br /> <br />REPORTS TO: 1- F <br />?.y <br />FAX NO.:( ) <br />C <br />N <br />T <br /> <br />COMP nalysis <br />Required <br /> <br />O <br />INVOICE TO: FK TW Oy QUOTE #: <br /> <br />2 SL SS P.O. NUMBER: A <br /> <br />R G <br />GRAB <br />LAB NO. SAMPLE IDENTIFICATION DATE TIME MATRIX S L/ <br />REMARKS <br /> U` O?7 ! q <br />1• ??i0 (( t5 ' , l <br />s' Z, ?s t / <br /> Oil 9.115 (-L20 S 4AJ <br />2 <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />5 <br /> <br />Collected/Relinquish?dH?y:(1) <br />Date <br />Time 4 <br />Received By: <br />Shipping Carrier: <br />Shipping Ticket No: <br />Samples Received Cold? (Circle) YES 7NY <br />Temperature C: /D, <br />Relinquished By: (2) Date <br />`/??/C(? Time <br />IJ? ? O Received By: <br />utj r ?(,,C, <br />r, T Special Deliverable Requirements: Chain of Custody Seal: (Circle) <br />INTA BROKEN ABSENT <br />Relinquished By: (3) Date Time Received By: Requested Turnaround Time and Special Instructions: <br />Relinquished By: (4) Date Time Received By: <br />