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Reporting Informs n <br /> f�met twn EZVtY01 nentgSelwork AEN Page—0 of - <br /> 1 Client � h V 3440 Vincent Road, Pleasant Hill 94523 <br /> Address 0 a S i QO REQUEST FOR ANALYSIS 1 CHAIN OF CUSTODY <br /> I <br /> (taht(ro Murt�ta. CA '9S(o�3 Phone((5 f 0)930-9090 __-- r1 r )'r , �1 "7 '� <br /> I FAX(510)930-0256 Lab Job Number r- <br /> i Contact 'T4$ a kla 4t <br /> Alt Contact y I SS-3 Lab Destination <br /> � Date Samples Shipped <br /> Address Report To Send Invoice To Lab Contact <br /> 29 C Date Results Required Sf4LJd,1rL <br /> Date Report Required <br /> Client Phone No (31103S4 - 3250 <br /> Client FAX No (916} 3 5'{" 32 5 1 <br /> ANALYSIS <br /> Send Report To V or 2 (Circle one) <br /> Client P O No Client Protect I D No N e s u w <br /> Sample Team Member(s) V It '1 KI t q <br /> 4 � <br /> Lab Client Sample Air Date/ Sample No T e a <br /> Number Identification Volume Time Type. Pres of o 2 �� Comments/Hazards <br /> Collected Cant Cont ,_ <br /> RECD S U— GW F17 F 0 500 v ter It 0 q t+ V3 <br /> ZMP 6- GrW 5M 100 Wal Pr I1 CI 4 Lt 3d <br /> S13 - GW 5 L8 1130 W,tff 1 1:11 4 Li 3V <br /> fL 5t5-- I� 51.ZS. 640 So, tar <br /> 5A 5$x- 20 SW BSo Soil -- BVASi <br /> LA - 39b- !U t 950 Sot - t3Yass <br /> t - 10 slit 1006 50tili t byai <br /> Bre S15 - 15 s ► oo Sot I 6'Q <br /> SG l —Z0 *11 1110 Sot I �YRbs <br /> (v< W I - S 5 26 tt t Soil - 1 13V14L5 <br /> (f/� Mw t --L5 511% 17? ul `� l 1ns4 <br /> I z t w1— Iq 310 94 <br /> Sot - rR <br /> 51k Mw Z - Z <br /> 510 10V 5-0 Iyp;S <br /> l�f,t MW 3— N19 100 nt — C3ra <br /> Relinquished by DATE TIME Received by } DATE TIME <br /> (Signature) 9 7 9 q $ (Signature) �9 `' t / <br /> / WAE4!�L <br /> TIME S"t <br /> DATE TMERelinquished by Recewed by(Signature) / ko (Signature) t �� , f � i f /i <br /> TIMEATE TIME <br /> Relinquished byReceived by <br /> ' (Signature) (Signature) <br /> Method of Shipment Lab Comments <br /> `Sample type(Specify) 1)37mm 0 8 pm MCEF 2)25mm 0 S pm MCEF 3)25mm 0 4 pm polycarb filter <br /> 4)PVC filter, diam pore size 5)Charcoal tube 6)Silica gel tube 7)Water 8)Soil 9)Bulk Sample <br /> < 10)Other 11)Other <br /> COPIES WHITE JOB FILE YELLOW PROJECT FILE PINK CLIENT <br />