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ENVIRONMENTAL 0/ Z CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT ORIGINAL <br /> r r Rush Analysis: 5 Days 2 Days 24 hrs. <br /> Client: w C 0 e e,t/0.S 7E Sampler Subject to surcharge <br /> Customer Number: /✓ QA/QC report required; yes , no <br /> Address: <br /> Electronic Data Transfer: yes no _ <br /> Comp Sampler Set up Date: Time: — If yes,To:State Client Other <br /> Phone: Zo 7 J d ` 7 q Time: s �/0-1,5 Mileage: �� Lab number: <br /> FAX: <br /> Project name: <br /> Lab Loc: SP ❑ STK ❑ V! ❑ ❑ <br /> Contact person: 15;0— e— <br /> /� <br /> Billing Information(if different from above) x <br /> u 3 <br /> Name: u <br /> Address: n <br /> V <br /> Oa 9 0 x4! <br /> Phone: Z, a i vuO, m O <br /> FAX: <br /> Ha , I o " `7� <br /> Contact person: y ;^3 9 U 1 •u e <br /> O. O G H y 0. t e) <br /> Purchase ordedcontrret/FGL quote number: c a� x E: Q <br /> Pre Log Required: yes __ no eb ° v z z Z o ^� Z <br /> ,qd' <br /> _ o _ <br /> Sample <br /> Location/Description Date Time � <br /> Number Sampled Sampled F z (✓ 00 a3 l.I H U <br /> 6✓ <br /> O <<A J , Ose� / V <br /> C,911. g O'J � <br /> 7Rece.ived <br /> to the teems and cawNtimc m the tevem dasuaeM <br /> Relinquished by Date, Tine <br /> Date�`/ [ Tme la/�. Received by: Dale Time <br /> by: Dale Tnce• Relinquished by: Date Time <br /> Date Received by: Dale Time <br /> CORPORATE OMCt!LABORATORY OMCR&LABORA Y <br /> rMwOrm <br /> P.O.Bac 7"VCaporati,at Sucet 2500 Slr Read <br /> sora Pa 3061 0272 Stock! 215 Yiad2 )734.947 <br /> Tel:(805 10 TeL(2l, 191 Td:(20 009)7 e7 <br /> Pn\ csuti 11„ Mobile(2091737•. <br /> nc, <br /> FAX(110))711"1ta <br />