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OVIRONMENTAL toCHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT AMIGINAL <br /> ILI <br /> Ctten tS�}n! J,�'*Gz�(f�" �,J �[r r(� Rush Analysts Yes-5Days _ 2Days_ 24hrs � <br /> Sampler(s) M.'��--�K�1 [ Subject to surcharge <br /> Customer Number 3— 2 <br /> �__� <br /> v b QA/QC report required yes no <br /> Address <br /> Comp Sampler Set up Date Time State Form required yes no <br /> l, �3t,�b <br /> Phone Y 6 t% 2 Time Mileage Lab number <br /> FAX ,/ 5 t C _g tl Lab Loc SP ❑ STK VI ❑ ❑ <br /> Project name C G[ <br /> Contact person <br /> Billing Information(1f different from above) <br /> ° x a <br /> Name � <br /> Address v p 3 x <br /> 0 0 0 <br /> m a o is N Z `y J <br /> Phone I� o c o eq <br /> FAX v °' �_ q o e <br /> N Z W <br /> Contact person R C7 li t e ny7 ° + � <br /> Purchase order/contract number U S ° pw�, O .'�a H 3 0 <br /> c Z 8 Z CO <br /> �. `� ep F <br /> c a, <br /> 11 <br /> RR 7 <br /> �P.. = <br /> W H W �7 N C7 �", A M1Y 11a V <br /> ° <br /> Sample LocatL0n/Descrlption Date Time �' _ �' 3 3 3 <br /> Number Sampled Sampled <br /> f, N x <br /> It 't ., .e •� ,r " H�0� 1 <br /> 3a <br /> 1 -771 <br /> R1 bedby end aub)ect to the terms and conditions on the reverie of this docum9m <br /> i`/►,. Deter f +Tnme iD- AAA��� RelinquUMdby Date Time <br /> Received by Date 2-Z 9t�I3me �fr'1 Received by Date Time <br /> 7!7 5 OO Relinquished by Date Time Relinquished by Date 71me <br /> Received by Date Time Received by Date 15me <br /> CORPORATE OFFICE dr LABORATORY OFFICE At LABORATORY FIELD OFFt E <br /> PO Box 272/853 Corpomian Street 2500 Stagecoach Road Ysalia,Cellfamla <br /> Santa Paula,CA 93061.4272 stock-CA 97215 Tel (209)734 9473 <br /> Tel (905)659-M 10 Tel (209)942-01 sl Mobile(209)737 2394 <br /> FAX (605)525 4172 FAX(209)942-0423 FAX(209)734-8435 <br />