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ENVIRONMENTAL CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> `` / ' / Q }, REPORTINFORMATION <br /> Xent I C(lq E�C(/ & Zaf3 Rush Analysis(surcharge will apply): <br /> 7CompSampler <br /> ❑New Customer Customer Number: ❑ 5 Day ❑ 4 Day ❑ 3 Day <br /> Address: - foo_ S/ /�,"� i Z ❑ 2 Day ❑ 24 hour <br /> L-Oy� 2 Time: Rush pre-approval by lab: <br /> q Yniul <br /> Phone: 6- SZ-fp � CLZ ( 3'�3 � Electronic Da[a Transfer: yes no <br /> 1 �2 Mileage: — <br /> FAX:-':%Q I �' �"I �r'1 If yes,To:State_ Client Oth� <br /> Project name: Shipping Charge: Pickup Charge: Lab number: V <br /> Contact person: <br /> Billing Info mn(if differ t from above) 1= i u c s <br /> et <br /> Name: et A U_ <br /> Addre <br /> 14 ^ CJ <br /> Phon <br /> D z" <br /> V - at FFo rn u Q W <br /> Contact rson: .10 Z H <br /> u �y r <br /> Purchase or ontract o m note number: E 8 `O <br /> o C U c m z` I"' <br /> Pre Log Required: yes M°ef❑ eaYJy O Quarterly❑ Lj Z = s atli� y Z Z W n <br /> E T o D z C <br /> .F� U 2 3 9 4SAMPLE y v V fy \ <br /> INFORMATION �.. v t a r .__ Fy ^rW �( <br /> rn .v l <br /> Number Location/Description Date Time bT', E °Sample <br /> ' 3 3 3 N n F F u S Z <br /> Sampled Sampled F Z [- E " 3 �' m m a <br /> �f Iz 3 l <br /> `� halt Q0 <br /> 0 <br /> a <br /> ro <br /> F <br /> Relinyoi,bed vane a 10 111e rand coMitions on the reverse Qtly/ryn rm/7rl ��//��}�� <br /> Date �u aL'��r.t�1 Y3D Rel...uia by ! Dat <br /> Received oY' DaleNrme `��(r7� Raeived by Datame <br /> , F7Reli�puisbad by: Due Tme I RelirpuishW by: Dn/v 1Tme <br /> Received by: Due Time Received by: Due Tme <br /> CONPOR7 OFFICE&LABORATORY OFFICE&LABORATORY FIELD OFFICE <br /> FO.Boa 2)2/853 ColFor"" Sue" 2500 Slagecoxh Road viulia,Califamia <br /> a Santa gala,CA 9J06102R <br /> Tel:IanS)659-0910 Smh,on,CA 95215 Tel:(559)))0.9473 <br /> FAX (805)525-41 R TeL 12091942-010.1 Mobile:(559)73)3399 <br /> FAX:(209)942-0423 FAX(559)714­8435 <br />