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_s www.tglinc.com UHAIN UP' UUJ1'UDY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS SAiMPLING1()N I IREPORTINFORMATION • <br /> VII <br /> �// f Zce,�C7(�n Rush Analysis(surcharge will apply): <br /> Client: r // �J// Sampler(s): <br /> s7kNew Customer s fCustomer tuber –�/-7-! / t/ ❑ 5 Day ❑ 4 Day ILI 3 Day <br /> A/d`dress: 73 5 N- r l hCi K ❑ 2 Day ❑ 24 hour <br /> Lti nal e. Comp Sampler Set up Date: Time: Rush pre-approval by lab: —T— <br /> Phone: ottoye G FAX: Time: Mileage: Electronic Data Transfer: yes no <br /> If yes,To:State ClientOther <br /> E-Mail 3 r0 <br /> Shipping Charge: Pickup Charge: Lab number. rzZcJ U <br /> Project name: <br /> Contact person <br /> Fizi.Billing lnfonna[ion(if different from above)Name: 0Phone: FAX: Z <br /> E-Mail (° q lu C4L4Contact person: (j vzt~ <br /> rn *Purchase order/contract/FGL uate number:q xMonthly 0 Weekly ❑ Qaanedy ❑ uOOPre Log Required: yes Frequency: other❑ Z <br /> o W <br /> SAMPLE INFORMATION ° a ri U3 `r'. `d 'm �• �` <br /> Sample Location/Description Date Time <br /> Number Sampled Sampled FT, Z F `✓C7 N m a d <br /> i by nndsubjem m lk msms and. ,uonvn the mverveo(ihis avmene <br /> Daa' T.i".� ��%0 Remw�i>nw nr: p> 7. - <br /> CORIPORATE <br /> Rmai.w by:Rellnpuiakd by. DaRelinquiahw by DmcrReceived by: -yDome 17e v Re«ived by: pum OFFICE&LABORATORY OFFICE&LABORATORY OFFICE&LA90MTORY FIELD OFFICE <br /> syIi Cory Ik CA Seem SWkan,500 CA 95215 Chi..CA959'_'tin� T:(559)j d73b9dTJ <br /> Senm05)3 CA S8060 Tel;(209)WU182 Tel:(fl0)34J-58 is <br /> Tel::(80(805)525 <br /> 17 FAX: Mobile_(5591331-1399 <br /> FAX:(m575'S41"!'_ 19aL00 Fe%�rM�anam+ - - <br />