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1 <br />CHAIN OF CUSTODY RECORD <br />AI sl?- SGS North America Inc. <br />O 1501?ast Patapsco Avenue Baltimore, MD 21226 Tel: (410) 355-1958 Fax: (410) 355-1965 <br />Box 850 Sophia, WV 25921 Tel: (304) 255-0422 Fax: (304) 255-0417 <br />O 216 Oxmoor Circle Birmingham, AL 35209 Tel: (205) 942-3120 Fax: (205) 942-0914 <br />O 5793 MacCorkle Avenue SE Charleston, WV 25304 Tel: (304) 925-6631 Fax: (304) 925-8877 <br />n <br />? 2979 East Center Street <br />0 1101 Howard Drive <br />? 4665 Paris Street, Suite B-200 <br />? 2804 Hackathorne Lane <br />O Route 2; Box 162A <br />? 15550 N. Lombard - Terminal 5 <br />O 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 Fa 3) 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. VV ? A P-5Th7' 2L ow SGS Reference: <br /> <br />l <br />I <br /> <br />CONTACT. <br />PHONE NO1 <br />D ) g/ <br />4 ?5/ p? r ?lJ <br />l ' l? ? v / PAGE OF <br /> 7 <br />? <br />t l <br />e J <br /> <br />PROJECT: SITE/PWSID# : <br />No <br />SAMPLE <br />TYPE Preservatives <br />Used <br /> Anal <br />sis <br />REPORTS TO: T <br />QO K L. Z8 <br /> <br /> <br />tJ? a 14 Z T L FAX NO.:( D) Sb4 Z= ?? C <br /> <br />0 <br />N <br />T <br /> <br />C= <br />COMP y <br />Required <br /> <br /> <br />3 f? <br />INVOICE TO: V rlAjto? D syL4 QUOTE #: <br />K (. 2 <br />t A 4 P.O. NUMBER: <br />2 A G <br /> <br />E RAB <br />f <br /> <br />LAB NO. <br />SAMPLE IDENTIFICATION <br />DATE <br />TIME <br />MATRIX R <br />S <br /> <br />REMARKS <br /> S 3 e9 .acv Z. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />5 4 <br />Collect I nq ' hed By:(1) <br /> <br />[ Date Time Received By: Shipping Carrier: <br />Shipping Ticket No: Samples Received Cold? (CircleL.'T-$„ NO <br />Temperature C: Q i -5 - <br />Relinquished By: (2) Date <br />teM <br />` loj Time <br /> <br />Ig 30 Received By: <br /> <br />6;? Special Deliverable Requirements: Chain of Custodv Seal: (Circle) <br /> <br />CNTACT BROKEN ABSENT <br />Relinquished By: (3) Date Time Received By: Requested Turnaround Time and Special Instructions: <br />Relinquished By: (4) Date Time Received By: