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.f hN <br /> i. Client F rr !� PSS Ames ICCIn L'nvi on111GntCIelwoik Pago of <br /> Address r� s 3440 Vincent Road,Pleasant Hill,CA 94523 REQUEST FOR ANALYSIS/CHAIN OF CUSTODY <br /> 57 Phone(510)930-9090 <br />! Contact FAX(5 10)930-0256 Lab Job Number <br /> All Contact ��S� Lab Destination <br /> Date Samples Shipped <br /> Address Report To <br /> Send invoice To Lab Contact <br /> 2- g Date Results Required <br /> Date Reporl Required <br /> Client Phone No <br /> Client FAX No <br /> Send Report To 1 or 2 (Circle one) ANALYSIS <br /> Client P O No Client Project I D No V <br /> Sample Team Member(s) <br /> Lab Client Sample Air Dale/ Sam le No Type <br /> Number ldenllficatlon Volume Time Y e* Pres of of <br /> Collected Cont. Cont Comments 1 Hazards <br /> 016d In 3-IS- 79 7 /- CL 2 ✓OkS <br /> 0 3 : ot <br /> -WA10 - 2: `{ I <br /> ML 33 <br /> I <br /> (Signatu e}Relinuishd by DATE TIME Received by DATE TIME <br /> (Signature) <br /> RelinquIsh(Slgriature)d by TE ,/ TIME Received by DATE TIME <br /> 'G(' f �. (Signature) <br /> Relinquished b DATE TIME <br /> (Signature) Received by DATETIME <br /> (Signature) ' <br /> Method or Shipment Lab Comments <br /> 'Sample typo(Specify) 1)37mm 0 a pm MCEF 2)2Smm 0 8 pm MCEF 3)25mm 0 4 pm polycarb filter <br /> 4)PVC filler, diam pore size 5)Charcoal lube 6)Silica gel tube7},Water 8)Sod 9)Bulk Sample <br /> 10)Other 11)Other ( <br /> COPIES WHITE JOB FILC YELLOW PnOJECT FILE PINK CLIENT <br />