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P� f� ,a- MAM ® User®DI? <br /> ANDANALYSIS REQUEST DOCUMENT <br /> REPORTCLIENT DETAILS • ' • <br /> Rush Analysis: 5 Days _2 Days_24hrs <br /> I� c 'l�U✓Ply,, Sampler(s): M ,�/��ci 1 <br /> Client: �( �'� <br /> Composite Sampler Setup: Subject to surcharge <br /> Customer Number:�� Date: Time: QA/QC report required: yes no <br /> Address: <br /> �l_ max G' Subject to Surcharge Field Sampler: If yes, To: State_Client _Other <br /> V' U ; 1 ^(/, Time Mdage: Lab number: 1 Cl SG 2.I ,Z - CP <br /> + � 1 <br /> Phone• �'�'� �''�`�- b�13 � SAMPLE <br /> CONDITION <br /> � 3 a <br /> FAX: <br /> Sample Temperature: Celsus <br /> �J� ( )Leaking. ()Broken. ( )VOA Headspace <br /> Project name: CA s a 6 Custody Seal()yes ()no <br /> NG 4 <br /> SAMPLE TRANSPORTATION <br /> Contact person: <br /> m m <br /> ()Ice Chest ()UPS ()Fed Ex Drop off ()Other <br /> SAMPLE INFOHMATION <br /> Sample Date Time <br /> Number Location Description Sample Sample <br /> CUSTODY <br /> Relinquished by Date�—T+ me 1 -Z s /Received by: DatC 2,IS Time t2 S7 <br /> Relinquished by: Date _Time Received by: I A Date Time <br /> Relinquished by: Date _Time Received by: Time <br /> 3935 N. Coronado Ave. * Stockton CA 95204 * Telephone (209) 477-8105 * FAX: (209) 546-7497 *-Eig-�jhvle@petallab.com jhvle@petallab.com * www.petallab.com <br />