Laserfiche WebLink
1 ENVIRONMENTAL CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT O R 1 G 1 Fv A L <br /> SAMPLINGCLIENT DETAILS SECTION I SEC-1-10N 11 101, <br /> FR�uAn' 1�Client: a Cp✓>7 /�(0 S r ¢�1t G / alysis: 5 Days 2 Days" ''24 hrs. <br /> Sampler(s) r_�� —� s r" Subject to surcharge <br /> Customer Number: report required:1 yes no <br /> Address: cDataTransfer yes no��Z Comp Sampler Set up Date: Time:f,I :State_ Client Other <br /> Phone: / 70 !12 ber;Time: Mileage:FAX: �IProject name: -1d0 N �c �Oe �6 � Sp ❑ STK:❑ VI ❑ ❑ <br /> r <br /> Contact person: �l i1 cs r O l r(_X LS/ <br /> Billing Information(if different from above) a w J <br /> Name n U as ! <br /> U <br /> Address: <br /> o o x <br /> y N <br /> p o f_ m <br /> FAX. -U o > ,r o .a r. N �? fi v <br /> � F � rn to 41 d :' <br /> oA a <br /> Contact person: a a 3 U u N z W a U <br /> a <br /> + <br /> `o f ❑ of v ct. <br /> Purchase order/contract/FGL quote number: o 'A a v I; CIOv o' <br /> Pre Log Required: yes no .R t? z ; b v a z O c, t, <br /> SAMPLE cGC w C <br /> INFORMATION N �' L �• j v ( �\ 0 Q.L7 Cwt <br /> w U m Nt�3 o d R O Q R d tea, <br /> [N,,mmpl,'e <br /> Location/Description Date Time a <br /> a c7 3 yr v y r e_— •�•�?-U <br /> ---. _-- --_ —— - Sampled Sampled- FE _z_ __ .S S .. - <br /> - :. <br /> t. <br /> ZK", Er c. [ DD <br /> ell, <br /> c Q 00 <br /> CUSTODY <br /> t A Relinquished by object to the terms and conditions on the reverse ofthisdocumeenu _ <br /> Relinquished by:, /� te��1+4 pale Time <br /> Received bY:,,11 Dat ' f�- � 75me ) ��✓ Received by: L Data -� Time,�' :iko <br /> RAWDated 1�— t D 7imc Relinquished by: Pate Time <br /> — <br /> y <br /> Datez-B::6LT me Received by: Date Time <br /> CORPORATE OFFICE&LABORATORY OFFICE&LABORATORY FIELD OFFICE <br /> P.O.Box 277453 Corporation Street 2500 Stagecoach Road (' r' 1";r; -'Ysalia.Caiaornis <br /> Santa Paula,CA 93061-0272 Stockton,CA 95215 9j f"}. _ ,� "'�41 ':Tel:(209)734-9473 <br /> Tel:(805)659-0910 Tel:(209)942-0181 _ ' ' Mobile;(209)737-2399 <br /> FAX:(805)525-4172 FAX;(2091942-0423 FAX 1209)734.8433 <br />