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CHAIN OF CUSTODY RECORD <br />SGS North America Inc. <br />Cl 1501-A East Patapsco Avenue Baltimore, MD 21226 Tel: (410) 355-1958 Fax: (410) 355-1965 <br />U P.O. Box 850 Sophia, WV 25921 Tel: (304) 255-0422 Fax: (304) 255-0417 <br />U 216 Oxmoor Circle Birmingham, AL 35209 Tel: (205) 942-3120 Fax: (205) 942-0914 <br />Cl 5793 MacCorkle Avenue SE Charleston, WV 25304 Tel: (304) 925-6631 Fax: (304) 925-8877 <br /> <br />? 2979 East Center Street Conneaut, OH 44030 <br />El 1101 Howard Drive Deer Park, TX 77536 <br />U 4665 Paris Street, Suite B-200 Denver, CO 80239 <br />U 2804 Hackathorne Lane Gillette, WY 82716 <br />U Route 2, Box 162A Middlesboro, KY 40965 <br />U 15550 N. Lombard - Terminal 5 Portland, OR 97203 <br />U 16130 Van Drunen Road South Holland, IL 60473 <br />Tel: (440) 224-2261 Fan: (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 />1 <br />CLIENT: \A ?? :4 JrL /t0L <br />SGSReference: <br /> <br />I <br />PAGE OF <br />CONTACT: r PHONE NO:( <br />) ¢ <br />iy <br />? <br />_ V 1 07 <br />9,V <br />L <br />/ <br />I V ``ff <br />ZS Preservatives <br />PROJECT: SITE/PWSID#: No SAMPLE <br />TYPE Used <br /> Analysis i <br />REPORTS TO: dK / Z8 <br />?P <br />B\I <br />FV L U 8'14 Z9 FAXNO.:(j70)8(. 2 C <br />O <br /> <br />T <br />COMP Required ??!1 <br /> <br />r1 <br />3 3 Vl <br />INVOICE TO: pA^T?? C, _k? S ,pQUOTE #: <br />?!f?j' o <br />Z`NO. NUMBER: <br />2 Ut ZZ - A <br /> <br /> <br />E <br />N GRAB rr <br /> <br /> <br />w <br /> <br />LAB NO. <br />SAMPLE IDENTIFICATION <br />DATE <br />TIME <br />MATRIX R <br />S <br /> <br />REMARKS <br /> . z9 16V Sa S cti `z <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> 4 <br />5 <br />Collecte uish :(1) <br />s''? yZ Date <br />z .co <br />C/ Time <br />1/0 -0 Received By: Shipping Carrier: v S <br /> <br />Shipping Ticket No: Samples Received Cold? (Circle), YES) NO <br />? ." <br />Temperature C: <br />Relinquished By: (2) Date Time Received By: Special Deliverable Requirements: Chain of Custody Seal: (Circle) <br />IWACTi BROKEN ABSENT <br />Relinquished By: (3) Date Time Received By: Requested Turnaround Time and Special Instructions: <br />Relinquished By: (4) Dat?rq O(( TimAe R GN d By: , <br />v..u.,.., onf...-H vvirh nnnrr <br />Pink - Retained by Sampler