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7_7 <br /> 1 ! 1 _ 1 '77--1 ..1 I- l4 l 1 J <br /> ENVIRONMENTAL CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT ORIGINAL <br /> � <br /> j Rush Analysis(subject to surcharge): <br /> �t N <br /> Client: 3.� L D. Q-eQ-60 0 '}' A&Q-O C. Sampler(s): ' ' ❑ 5 Day ❑ 4 Day ❑ 3 Day <br /> ❑New Customer 1 Customer Number: <br /> Address _'2A 'L1605--row 1_0 _ ❑ 2 Day ❑ 24 hour <br /> Lot).) �',A �2� � Comp Sampler Set up Date: Time: Electronic Data Transfer:eyes no <br /> Phone: 3 12 7 ' '3 701 <br /> Time: Mileage: If yes,To:State_ Client Other <br /> FAX: <br /> Project name: -4 I?A;x3C_t{d Teof Vtl Lab number: i <br /> Contact person: <br /> Billing Information(if different from above) <br /> Name: 2 h <br /> h ° <br /> �: 3 a` 2 <br /> Address: <br /> y <br /> „ O <br /> m � <br /> Phone <br /> o v 1" Q ° a <br /> :� <br /> FAX: - U a <br /> o <br /> `n U <br /> ro <br /> Contact person: o a 3 3 A U N Z ~ p <br /> + — <br /> Purchase order/contract/1713L quote number: <br /> U u <br /> ° <br /> Pre Log Required: yes no ;Q z u 2 <br /> C) z 33 ' rn y x v �� ti <br /> _ <br /> Sample Location/Description Date Time c $ a v " 2: z h <br /> NumberSampled Sampled FT z <br /> G <br /> C <br /> REMARKS SFCTION V mow, <br /> CUS'YODY SECTION V] <br /> A <br /> r <br /> J <br /> hed by and sub- t to the terms and conditions on the reverse of this document: ��1 <br /> Date Time��,,{/ Relinquished • �-' Date Time <br /> Received by Date �Nio Time�� G�` Received by: Date . • Time <br /> Relinquished by: Date _Time Relinquished b Date Time <br /> Received by: Date Time Received by: Date <br /> Time <br /> CORPORATE OFFICE&LABORATORY OFFICE.&LABORATORY FIELD OFFICE <br /> PO.Box 2721853 Cotparatinn Street 2500 Stagecoach Road Visaiia,California <br /> Santa Paula,CA 93061-0272 Stockton,CA 95215 Tel:(209)734-9473 <br /> Tel:(BW 659-0910 Tel (209S1142-0181 Mobile:(209)737-2399 <br />