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www.fglinc.com <br /> CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> r <br /> cc <br /> 17'L)U­11 k�ZO I',,, F ��l W <br /> 1 -1 n M, <br /> Rush Analysis(surcharge will apply): <br /> Client: P, Sampler(s) <br /> U New Customer Customer Number: Q 5 Day U 4 Day 0 3 Day <br /> Address: <br /> ant Comp Sampler Set up Date: U2Day 12 24 hour <br /> FAX: Time: Rush pre-approval by lab: lattal <br /> Phoneli�?'.11&&f—gig q I Electronic Data Transfer: yes no <br /> E-Mail Time: Mileage:— I If yes,To:State ClientOther <br /> Project name: ALLC-44 Pickup Charge: <br /> Shipping Charge: Lab number: <br /> Yh <br /> Contact person: <br /> Billing Information(if different from above) <br /> Name: <br /> Address: <br /> 0 <br /> Phone: FAX: 0 b <br /> E-Mail <br /> 0 <br /> Cn <br /> 0 <br /> Contact person: d 0 <br /> Purchase order/contract/FGL quote number: + <br /> 0 z z 0 <br /> Monthl <br /> U 0 <br /> Pre Log Required: yes Frequency. b <br /> 0 <br /> W, 1 0 IN\ I > <br /> a <br /> 0 .0 t 0ampe <br /> .1 t <br /> T, Location/Description Time CA <br /> S%t 0. 0 <br /> FN 0 <br /> ampled z <br /> 8(Ali L- _ V <br /> P171 LIC-f 9LL- J obao <br /> c1\4 I I <br /> C1 <br /> "rinomw <br /> Rell 'bed by and subject the terms and co 'tions on the reverse of thi d t: <br /> J <br /> Time Relinquished Date Ok*ime <br /> I <br /> en, <br /> T <br /> Received by: Date Time R I eceived by. AJ Date me <br /> Relinquished by: Date Time Relinquished by: � Date Time <br /> T_= <br /> IFReceived by: Date 4' ime� Received by: �J Date Time <br /> CORPORATE OFFICE&L ABORATURY OFFICE&LABORATORY <br /> 853 C 25M Stagecoach Road OFFICE&LABORATORY FIELD OFFICE <br /> Santa Corporation <br /> 'R Street <br /> Stockton,CA 95215 563 E Undo Avenue Visalia,Califomia <br /> Tel:(805)392-2000 Tel:(209)942-0182 Chico.CA 95926 Tel!(559)734-9473 <br /> FAX:(805)5-7541-r— PA Y.rino)0A1— Tel:(530)343-5818 Mobile:(5591737-2399 <br />