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ENVIRONMENTAL AND OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT ORIGINAL. <br /> TOWFINFORNINHON <br /> CLIENT DETAILS RE <br /> / Rush Analysis: Yes—5 Days — 2 Days, 24 hrs._ <br /> Client: Sampler(s): � /` /� cti sic� Subject to surcharge <br /> Customer Number. — `Zb g <br /> � -� QA/QC report required: yes no _ <br /> Address: _ <br /> State Form required yes no <br /> Comp Sampler Setup Date: Time: ����'�_ <br /> Phone: Time: [46,54r Mileage: Lab number: <br /> FAX: <br /> Lab Loc: SP ❑ STK ❑ VI ❑ ❑ <br /> Project name: + _ <br /> Contact person: �' S -�Au�IP-� _ <br /> Billing Information(if different from above) _ <br /> u <br /> u <br /> ame: d :: <br /> Address- > = d 3 a x <br /> z O <br /> Phone- a L Cq o ^, <br /> FAX: :? u _ d o c C M <br /> o N z <br /> Contact person: E C7 F n ° + 6 1 o <br /> .r <br /> Purchase order/contract number. Z u y a p o Z <br /> —, <br /> e c 0 3 3 N 4 x ll b All <br /> .�" <br /> U <br /> w a L o v �= > <br /> p ren r sc <br /> o <br /> Sample Location/Description Date Time a <br /> 3 .. <br /> U � <br /> Number Sampled Sampled P Z IEWA'I °3 m d ` U <br /> 3� i <br /> CUSTODY CTION \11 <br /> Relinquished by and subicct to the terms and conditions an the reverse of thiw docuenc <br /> t } <br /> Dace tZ 7l Time 3•`£� Relinquishcd by: Date Timc <br /> r z <br /> 'Z <br /> n <br /> Received by: Date 14 Time�+/1�6 Received by: Date 'i imc <br /> Relinquished Dau Time Relinquished by: Date Time <br /> Received by: Due Time DzvTime <br /> CORPORATE OFFICE&LABORATORY OFFICE&LABORATORY FIELD OFFICE <br /> P.O.Bos 2T2/85 r'�rporacion Street 250n Stagccoar Road Ysalia,California <br /> Sams Paula -0272 Stockton, Tel:(209)734 94 <br /> 73 <br /> Tcl:(805)65 Tel:(2091 Mobile:(20917 9 <br /> FAX:(905)52:, PAX:(209) FAX(209)734-8435 <br />