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ENVIRONMENTAL CHAIN OF CUSTODY OPIGINAL <br /> ANDANALYSIS REQUEST DOCUMENT <br /> .�.f Cron,, a/ Rush Analysis(subject to surcharge): <br /> Client I Sampler(s): CC�X.� F� <br /> ❑ 5 Day ❑ 4 Day ❑ 3 Day <br /> Ll New Customer Customer Number: <br /> Address: I J .l / r ❑ 2 Day ❑ 24 hour <br /> Comp Sampler Set up Date: Time: Electronic Data Transfer: yes no <br /> Phone: �:,-/ "" `�^' �') Time: Mileage: yes,es,To:State_ Client _Other <br /> FAX: ��Lab number: <br /> Project name <br /> Contact person: <br /> Billing Information(if different from above) F�281 <br /> NSName: - <br /> Id a <br /> Address: <br /> 0 <br /> o Z iz <br /> is <br /> Phone: 6�a^ <br /> .O <br /> FAX: <br /> Contact person a ,o o <br /> y <br /> a>' <br /> ,+ <br /> `C <br /> p ti <br /> Purchase order/contract/FGL quote number: o <br /> ll <br /> Pre Log Required: yes no 2TF <br /> SAM 'IT INFORNIA I ION SECTION IV <br /> Date Location/Descriptiona <br /> umber SampledSampledT <br /> Z' <br /> six <br /> iIS <br /> , <br /> : <br /> C <br /> Q <br /> F <br /> clinquixh by11 Oki CUSTODY SEC-1 ION V1 <br /> 77 glmn hewn an themvemcafa,ld me <br /> , ^ Darc- LC L7 Time Relinquished <br /> by, Dare 'I Tine,/' •— <br /> Received by v� D. Time Received by: Date Tim <br /> Reinquishedby: Date Time—//I�—!}J1� Relinquished by: Dne time <br /> Received by: Dare Timef Receivedby: Data Time <br /> CORPORATE OFFICE 6 LABORATORY OFFICB&LABORATORY FIELD OFFICE <br /> P.O.Box 2721853 C ration Street 25110 Stagaoech Road Visalia, )734mia <br /> mpo Stockton.CA 95215 Tel:(209)]14-9473 <br /> sante Faula,CA 93061-0272 Tel:(209)942-0181 Mobile(209)737-2399 <br /> T61:(805)659 0910 as <br /> FAX:(M)525d172 FAX:(209)942-1127 FAX(209)]70.8433 <br />