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Reporting Iniormati *,, <br /> � T� I-3ooQ1 10"I <br /> t111 Client k rf. _ An1['1 scan Et vu� nmental k L/�i, Page `, <br /> Address tNE Fi 3440 Vim_(,n[Road Ph_ja and Ifill,CA 94523 `* <br /> [rsl , - fhonc(510)93p-9090 REQUEST FOR ANALYSIS I CHAIN OF CUSTODY = ;,. 4 <br /> Contact�gr FAX(510)930 0256 Lab Job Number a-�O t <br /> All Contact Lab Destination <br /> Date Samples Shipped <br /> Address Report To Send If To Lab Contact <br /> 2 _ 3 — Date Results Required <br /> r Date Report Required <br /> Client Phone No i <br /> L.�Ci T4f, C Client FAX No <br /> ANALYSIS <br /> Send Report To 1 0170 <br /> r 2 Circle one) <br /> Cknl A O No Client Pro;ect I D No _ 0 <br /> Sample Team Member(s) <br /> I � <br /> Lab Client Sample Air Date/ Sample No <br /> Number Identification Volume Time Typeof <br /> Collected Coni Cant Comments/Hazards <br /> 0l Pi /_ -�3 ! r� <br /> .19 <br /> � t <br /> c! r <br /> ^ n <br /> 4 <br /> Relinquished by DATE TIME Received by DTE TIME <br /> (Signature) U (Signature <br /> Rei �j <br /> m Y <br /> Relinquished b ( TE � <br /> q ¢ ME Received by 1� <br /> (Signature) �� 3 �DATIME DATE TIME-� '� ! /�` VC, (Signature) 3 `f ��jo <br /> -0 -6n up <br /> Relinquished by ANXT <br /> TIME Received by DATE "TIME`. L <br /> (Signature) ;� p OD (Signature) _ <br /> Method of Shipm nt Lab Comments I ,; <br /> tt <br /> 'Sample type(Specify) i)37mm 0 8 um MCEF 2)25mm 0 8 um MCEF 3)25mm 0 4 Nm polycarb filter <br /> 5 <br /> 4)PVA;.filter, diam ^__ pare 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 /> ,t <br /> r <br />