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Reporting 1Mor <br /> I Client � ,� � f, ` Amei scan En vii nnmenta0et"'01 k <br /> AEN <br /> Address �. i ;l �7� 3440 Vincent Road Plc"tti,rnt [fill CA 94523 Page of <br /> IV <br /> Phony (510}910 9090 REQUEST FOR ANALYSIS/CHAIN OF CUSTODY <br /> Contact W fj1 I AX 010)910-0226 Lab Job Number <br /> Aft Contact . <br /> Lab Destination <br /> Address Report To Send Invoice To Lab Contact <br /> 2 <br /> "'x 1t r ,, �,e n_,5 3 Date Results Required <br /> Date Report Required <br /> I rF r , ! '+ Client Phone No <br /> Client FAX No <br /> Send Report To 1 or 2 (Circle one) ANALYSIS <br /> Client P O No Client Protect I D No 1 <br /> Sample Team Member(s) v <br /> Lab Client Sample Air Datet Na Type <br /> Number Identification Volume Time Sample Pres of of <br /> Collected Type" <br /> Cont Cont <br /> ,1 - U — Comments I Hazards <br /> 7_ -I/A ' <br /> Relinquished by ) t <br /> . ,, DATE rTrfME(Sr natureLr Received by <br /> 1 <br /> DTE TIME <br /> (Signature) , <br /> Rel+nqu+shed by w . ' DATE ` <br /> AIME <br /> (Signature) — y Received by / DATE'f TIME <br /> (Signature) <br /> Relinquished by DATE <br /> (Signature) TIME Received by / DATE TIME <br /> (Signature) �' ', f c s C-_ ` �,t ' / <br /> Method of Shipment <br /> Lab Comments -{ <br /> Sample type(Specify) 1)37mm 0 8 pm MCEF 2)25mm 0 8 pm MCEF 3)25mm 0 4 pm polycarb filter <br /> 4) PVC filter dram pore size 5}Charcoal tube 6)Silica gel tube 7)Water 8)Soil 9) Bulk Sample <br /> 10)Other 11)Other <br /> COPIES WHITE JOB FILE YELLOW PROJECT FILE PINK CLIENT <br />