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ft <br /> " ENVIRONMENTAL AND OF CUSTODY ORIGINAL.` AND ANALYSIS REQUEST DOCUMENT <br /> //�•,,�, 7 Rush Analysis(subject to surcharge): <br /> Client "� C67�a"-- rSampler(s): l_G(/Y 115 1--k0 New Customer Customer Number: - ❑ Jr Day ❑ 4 Day U 3 Day <br /> Address: 1t`Qsrs� , ❑ 2 Day ❑ 24 hour <br /> pler Setup Date: Time: _ Electronic Data Transfer: yes no <br /> Phone: ' <br /> Time:me: Mileage: _ If yes,To:State_ Client _Other <br /> FAX:_ 6 ��j�' "_ - Jl /, { 1 <br /> Lab number: <br /> Project name: ) <br /> Contact person' /hi 1 D S to <br /> n <br /> illing Information(if different from above) - - F+ e I <br /> . ct <br /> u � U v <br /> ame: y 3oa z or -4 <br /> Address: <br /> 3 Q v w Q <br /> C7 O 3 x y 0 a O O �'x <br /> o z v I <br /> Phone: to v <br /> FAX: - 0 y tz, �o• m ry �,c ci I US <br /> Contact person: °i �+ 3 3 ^� U -• .� z7 <br /> + <br /> Purchase order/contmct/FCL quote number: o U G 10 y <br /> U c U z afii a z O CV c C <br /> Pre Log Required:. yes no 7� a c y <br /> �j rn K w $ <br /> o y D <br /> SEC]ION IVSANIPLE INFORMATIONN o c v E g rn y .. r > y <br /> o v m y kT is _ R -ON <br /> O D O O O ..] �. N a '• <br /> Sample Location/Description Date Time `" WF, I-: x ,•L a ,k <br /> Number Sampled Sampled F Z [-'' w m v S tq �" p, Q -E+ U q <br /> A" A-KAY _ 0 <br /> C <br /> a <br /> n <br /> a <br /> F <br /> Oki <br /> Ti <br /> IN .. a <br /> linqui ed by dmbjccno ndlilnn�on the rraera of lM1 U p •) <br /> f) Daie ec Q�Tlme � 5 �Rel'nyu sM1cd by. w Date Time <br /> a <br /> R e t /�^� Time�'�..�a�-�-- Received by .._ .Due •I' Timc <br /> Rditu,tkledb Da Time,p�O Relinquished by: Date Tmc <br /> Receivedby: Dale - Time '$��-1` Rmcae,vxdh, D. <br /> 7 i <br /> CORPORATE OFFICE&LABORATORY OFFICE LABORATORY FIELD OFFICE <br /> P.O.Boz 272/853 Catporaion Stied 2500 Slagccoach Rood Ysalia,California <br /> Santa Paula,CA 9306141272 Slaklon,CA 95215 Tel-(209)734-9471 <br /> Tek(805)6590910 - Tetl'-091942-0181 Wbilc:(2N)737-2399 <br />