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CHAIN OF CUSTODY <br /> www.fglinc.com ANDANALYSISREQUES TD0CUMENT ORKWM <br /> OEM <br /> Client. �I Sampler(s): ,(, (,,,, Rush Analysis(surcharge will apply): <br /> ❑ New Customer Customer Number: .3-1 yq zd 05 Day 04 Day 03 Day 02 Day ❑24 hour <br /> Addres Rush pre-approved by lab: <br /> �, `' 3 (?A �� Comp Sampler Set up Date: Time: Electronic Data Transfer:Oyes Ono <br /> Phone:J060-07(0"1 �D � Fax: Time: Mileage: If yes,To:State Client Other <br /> E-Mail: -��n,� �'�, Shipping Charge: Pickup Charge: Lab number: 5S <br /> Project name: >;1yy ' �t/ d rrc,�. IraC(i1 <br /> Contact person: U <br /> Billing Information(if different from above) a F o <br /> Name: �? _ 3 0 3 o v <br /> Address: Q,a o 0 3 o a 0 s <br /> a m Nd <br /> C 3 v z 0 <br /> Ci a <br /> 8 .2 C' •o a N N C <br /> Phone: Fax: N o c o �° ,�, a o w <br /> �+ n M - u v o c to F <br /> E-Mail 0a 3 W :3 m a N '6 w <br /> 0 3 m^3 v •- m a + z <br /> Contact person: o L t? 4 o a = a <br /> u M w <br /> Purchase order/contract/FGL quote number: m ra ;, z0 ? N o � z o" S <br /> Monthlyo WeeklyO Quarterlyp 0 a 3 3 m a _ Q Z <br /> Pre Log Required:yes Frequency:otherp o c ? 3 N N <br /> to - u .0 '�' o m v P - a t) (n <br /> 0 -0 000 0 `^ � 3 o m m ) v (A Q <br /> Sample Location/Description Date Time a a> a 3 to a, 2 z <br /> Number Sampled Sampled FT z H? a c? m m m d a ? <br /> t (So K 2 l <br /> u. a z i <br /> F7 IIIWA 9X4 FRelinqoished <br /> ash nd subject to the terms and conditions on r`j�a this docs t• <br /> Date: 1 Time:2 _Relinquished by: Date: Time: <br /> d by: Date: Time: 3�Recelved by: Date: Time <br /> IV IV <br /> by: Date: Time: "— Rellnqulshed by: Date: Time: <br /> d by: Z&2 Date: Time: Received by: Date: Time: <br /> Corporate Offices&Laboratory Office&Laboratory Office&Laboratory Office&Laboratory Office&Laboratory <br /> 853 Corporation Street 2500 Stagecoach Road 563 East Undo Avenue 3442 Empresa Drive,Suite D 9415 W.Goshen Avenue <br /> Santa Paula,CA 93060 Stockton,CA 95215 Chico,CA 95926 San Luis Obispo,CA 93401 Visalia,CA 93291 <br /> TEL:(805)392-2000 TEL:(209)942-0182 TEL:(530)343-5818 TEL:(805)783-2940 TEL:(559)734-9473 <br /> FAX:(805)525-4172 FAX:(209)942-0423 FAX:(530)343-3807 FAX:(805)783-2912 FAX:(559)734-8435 <br />