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<br />CHAIN OF CUSTODY RECORD ? 2979 East Center Street Conneaut, OH 44030 Tel: (440) 224-2261 t-_. 440) 224-2808 <br /> S G S 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 />U 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 />Box 850 Sophia, WV 25921 Tel: (304) 255-0422 <br />U P.O Fax: (304) 255-0417 ? Route 2, Box 162A Middlesboro, KY 40965 Tel: (606) 248-4205 Fax: (606) 248-0044 <br />. <br />U 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 />CLIENT: VV?TEZ -U,FlS C:n-owbo <br />v v SGS Reference: PAGE OF?- <br />- <br />f <br />. ' o A p T <br />- <br />?, ) <br />PHONE NO: <br />CONTACT: <br />c <br />1 - ` Preservatives <br /> N o SAMPLE Used <br />PROJECT: SITEIPWSID## : <br />C TYPE <br />Analysis <br />REPORTS TO: r ?} <br />Q Ox?2$ <br /> <br />nu VtC)a Q IQZ4 FAX NO.:c l70 <br />NN 0 <br /> <br />T <br />C= <br />COMP Required <br /> <br />/ <br />O N <br /> <br /> <br />INVOICE TO: :MY5f C?ls QUOTE #: <br />07, <br />C bZ0 r7 I P.O. NUMBER: <br />2 D <br />A <br />I <br /> <br />E <br />G_ <br />GRAB <br /> <br />i <br /> <br />LAB NQ. <br />SAMPLE IDENTIFICATION <br />DATE <br />TIME <br />MATRIX R <br />S <br />REMARKS <br /> 6 c? a <br />11 <br /> <br />, 2 <br /> <br />g 5/11 <br /> <br />2, <br /> <br />?j <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> 4 <br /> 5 <br />Collected/ uis d By:(1) <br />/ Date <br />_Z`I <br />/ Time <br />B Received By: Shipping Carrier: LA?s <br />Shipping Ticket No: Samples Received Cold? (Circle YES NO <br />Temperature C: t <br /> Relinquished By: (2) Date Time Received By: Special Deliverable Requirements: Cha_?--of Custody Seal: (Circle) <br />INTACTBROKEN ABSENT <br /> Relinquished By: (3) Date Time Received By: <br />* Sp <br />Requested Turnaround Time and Sp <br /> Relinquished By: (4) Cate Time Rece ed By: