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25^,FRESNO STREET <br />M;r6NO, CA 93721 <br />L A e I R A r o R i E s, i N c. (559) 268-7021 rAk- (559) 268-0740 <br />CHAIN OF`CUSTODY/ANALYSIS REQUEST <br />REPORT TO: INVOICE TO/COPY REPORT: (Circle one) REGULATOR (CIrde one) <br />ATTENTION ATTENTION: State Dept. of Health (DOHS) <br />NAME:y2 W L NAME: - Fresno Madera Madposa <br />ADDRESS:ADDRESS: Tulare Iangs' Merced Kern <br />Other: <br />PHONE: <br />FAX: CONTRACT/P.O. # <br />COMMENTS r, OC- BACTERIOLOGICAL SAMPLES ONLY PROJECTINFO: <br />' PUBLIC <br />ROUTINE <br />SURFACE WATER <br />REPEAT <br />' <br />CONSTRUCTION <br />REPLACEMENT <br />PRJ#: - <br />OTHER <br />OTHER <br />MGR: <br />PRIVATE <br />ANALYSIS REQUESTED <br />TUPAVAOUND REQUESTED: (Circle one) Cej S <br />c' D te): <br />OUTIN Ll <br />- <br />i <br />.�-. <br />INT E): <br />7- <br />SIGNATU - ... ..,. <br />k <br />_CC <br />TYPE KEY: Drinking Water -DW 'Gteund Water -GW -Other-0 (Describe in Comments) <br />,� <br />to <br />SurfaceWater-SW Storm Water -STM Biosolid-BS Waste Water -WW Solid/Soil-SL <br />ID# <br />SAMPLE ID <br />SAMPLED <br />TYPE <br />DATE TIME <br />r <br />C <br />RELINQUISHED BY COMPANY�.� ,TE TIME; ;K " RECEIVED BY COMPANY - - <br />42,/ _ - <br />