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CHAIN OF CUSTODY <br /> • I www.fglinc.com AND ANALYSIS REQUEST DOCUMENT,CLIENT DETAI LS ` <br /> SECTION1 <br /> Client: i 1 442 Sampler(s): Rush Analysis(surcharge will apply): <br /> 13 New Customer Cu tomer Number: '� E15 Day 04 Day 03 Day 02 Day 024 hour <br /> Address: ��' ( <br /> Rush pre-approved by lab: <br /> Comp Sampler Set up Date: Time: Electronic Data Transfer: ❑yes Ono <br /> Phone: -76,Fax: Time: Mileage: If yes,To:State Client Other <br /> E-Mail: Shipping Charge: Pickup Charge: Lab number: <br /> Project name: ��; LL , tM/' tis �-(� �S �p,�-(,^ <br /> q3 -31 <br /> Contact person: <br /> Billing Information(if different from above) Q 1 0 <br /> Name: o r, <br /> Address: t�i/li Vit,' L"') 2 U a o - Q-- o -C <br /> l7 0)Y cc v O M ' <br /> v Z Z O <br /> N <br /> Phone: —71 ),-L(C6 d Fax: `�' aj �' <br /> v o > .E o `� ,� v Q O w 1 <br /> E-Mail: a -2 a I- v <br /> � v - N w J ra <br /> o m a + Z t 'J <br /> Contact person: o G � a F OS a v <br /> Lu <br /> Purchase order/contract/FGL quote number: Y c Z Y o z o <br /> iz <br /> Monthly❑ Weekly❑ Quarterly❑ - c a ro > � _ <br /> Pre Log Required:yes Frequency: other❑ v° ? 3 <br /> c v c a - a n SAMPLE - <br /> INFORMATION <br /> 1 SECTIO i Ln o v- n o o O <br /> p o ¢O � L,) _. cr A ) QJ <br /> to <br /> Sample Location/Description Date Time Q Q; a v U U JQ <br /> Number Sampled Sampled z I— m m m a <br /> C l ec �' )`> <br /> +t— <br /> ' REMARKS 1SECTION VI <br /> Itcli wished by ad s tt t re terms and conditions on th•reverse of this docum%nt:/ C <br /> Date: (' Time: l J' Relinquished by: Date: Time: <br /> Received by: are: Time: Received by: Date: Time: <br /> Relinquished by: Date: Time: / ✓" Relinquished by: Date:. Time: <br /> Received by: i� Date: Time: 17 Received b�: Uat�4l Time: <br /> Corporate Offices S Laboratory Office&Laboratory ffice 8 Laboratory Office 8.Laboratory Office&Laboratory <br /> 853 Corporation Street 2500 Stagecoach Road 563 East Lindo Avenue 3442 Empresa Drive,Suite D 9415 W.Goshen Avenue <br /> Santa Paula, CA 93060 Stockton, CA 95215 Chico, CA 95926 San Luis Obispo, CA 93401 Visalia,CA 93291 <br /> TEL: (805)392-2000 TEL: (209)942-0182 TEL:(530)343-5818 TEL: (805)783-2940 TEL: (559)734-9473 <br /> FAX: (805)525-4172 FAX: (209)942-0423 FAX: (530)343-3807 FAX: (805)783-2912 FAX: (559)734-8435 <br />