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r r r rr <br /> 1 Client c t�`"� '��^�� a�^+ <br /> 11L'1 I on ILII U Page <br /> s 3440 VInLL111 Ru,irl PIC&I,,nt Hill C _,_3 REQUEST FOR ANALYSIS I CHAIN 0 CUSTODY <br /> Address <br /> S t? T 4 /I t Phone O10)9 34)-9090 <br /> Contact 7'e �� W r c v I AX(510)930 0256 Lab Job Number <br /> Alt Contact J`, a' Lab Destination <br /> Date Samples Shipped t `'�3 1-(-7 <br /> Address Report To Send Invoke To Lab Contact <br /> Date Results Required <br /> 2 3 <br /> Date Report Required <br /> Client Phone No `� ` 5�` <br /> Client FAX No el S <br /> ANALYSIS <br /> Send Report To 1 or 2 (Circle one) <br /> Client P 0 No 1 _ - 'l Client Prolcct I D No _ WContQj <br /> Sample Team Member(s) No Lab Client Sample A�t� Time Sample Pres ofNumber Identification Volume Type` Comments!Hazards <br /> Collected ConE <br /> dlr� S <br /> I <br /> Relinquished by DATE TIM Received by /l DATE TIVIIE I <br /> (Signature) lv� r j ( J (Signature) �(� "9 II <br /> Relinquished bg DATE TIME Received by DATE ZIME <br /> (Signature) t %' + - �0 (Signature) E i ; / [)- j = C ) <br /> Relinquished by DATE TIME Received by t DATE aTIME <br /> (Signature) (Signature) [ <br /> Method of Shipment 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 />