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1 t 5 <br /> 1 <br /> ENVIRONMENTAL AND OF CUSTODY OwGINAi <br /> AND ANALYSIS REQUEST DOCUMENT <br /> 4 <br /> 1 ien[: l E t wrJ V U4,P"N Sampler(s):� f Rush Analysis(surcharge will apply): <br /> ' <br /> a New Customer . Customer Number- ❑ 5 Day IJ 4 Day ❑ 3 Day <br /> Address: P o- f3ox - 2.t So ❑ 2 Day ❑ 24 hour <br /> ' C- q 2-4 { Comp Sampler Set up Date: Time: Rush pre-approval by lab: <br /> inital <br /> Phone: � 3 —6C�f 3Time: Mileage: Electronic Data Transfer: yes no <br /> FAX: C?� 334—a-7 Z3' If yes,Tw State qienit O er <br /> Project name: ./PCE Shipping Charge: PickupCharge: Lab number <br /> Contact person: (�r 2 <br /> Billing Information(if different from above) <br /> o <br /> ( Name: <br /> Address: <br /> a = 0 3 lam- a o <br /> rb3O v z <br /> Phone: u o m Y b v <br /> U -U o A G ip o p <br /> FAX: y c0. F n rn v ¢ N W <br /> Contact person: 0. 3 m 3 d � <br /> O � F Arpt <br /> Purchase order/contracdFGL quote number: o t2 0 9� V W x0 ww5..!! <br /> Fre <br /> Monthly ❑ Weekly❑ Quarterly ❑ V E O z V V F a Z O \ r <br /> Pre Log Requenc <br /> uired: yes 9 y Other❑ = > u z <br /> o c z 3 3 0 <br /> U c m W <br /> rn o o � g � � � � '� p ,y.r <br /> U ye � 3 _ c m <br /> x C a <br /> Cq <br /> Sample g Location/Description Date Time <br /> Number Sam ]ed Sampled E' Z HT a ?3 `�' 60m a F `— Q' <br /> a G 1 1 1014 7zl <br /> Boo <br /> MPl_G <br /> 7'44&4 6 9"s <br /> —ELL <br /> I :'I CUSTODY Sl:CTION V1 <br /> Q <br /> o <br /> �- <br /> ,- Relipquished nd s jecl to[he terms and co n[e reverse a(this d <br /> h4/ Date97777 Time <br /> �, Dale <br /> Received Dy: Date F 1 1 Date lou, <br /> _ Relinquished by: Date f Date Time <br /> - Reeeived by: Date Daze Time . <br /> CORPORATE OFFICE&LABORATORY OFFI( FIELD OFFICE <br /> P.O.Box 272!853 Corporation Sireet 25005 Visalia,California <br /> Santa Paula,CA 93061-0272 Sloekbi Tel:(559)734-9473 <br /> Tel:(805)659-09]0 Tek(I Mobile:(559)737-2399- <br /> FAX:(805)525-4172 FAX:I FAX(559)734-8435 - <br />