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( ENVIRONMENTAL CHAIN 01% C,tUSTODY ORIGINAL <br /> ANOANA LYSIS REQUEST DOCUMENT <br /> DI U�7►J M Ul�(�N Rush Analysis(surcharge will apply): <br /> Client:. -- — Sampler(s): _ <br /> U New Customer Custrnncr Number: ���i'.0 0 U 5 Day ❑ 4 Day U 3 Day <br /> nthhr55 (�, u. IBX I �3� — ❑ 2 Day ❑ 24 Hour <br /> L )b 1 f (� S U ('Amp Sampler Set up[),art:. l inic. —_-- Rush pre-approval by lah: <br /> Phone: 1G1rI ( V Electronic Min Transfer es nu <br /> --- ------------- 'little: Mileage: <br /> PAX:_ -- <br /> If yes,To:State _ 'jrnt )Ihcr <br /> j�a/ZE� s�y,n ���ul(�+/� Shipping Charge: Pickup Charge: lab number <br /> Project name: <br /> Contact person: /`�����--�' �� ` h✓� /I �r�--- � <br /> Rilling Information(it dillrien(front above) I a <br /> Name:- --—---- — " 5, V <br /> r � = x <br /> a ai, <br /> Address: <br /> L <br /> _ CJ p 3Y = O o Q 0 <br /> I'honr: o m O 3 t Z C <br /> c > o r' o <br /> o c <br /> IAX: - --- v n. u S F- <br /> 0 Q <br /> C'ontart prrsrtn: o a D 3 �lI 3 Q a ti 7 <br /> Purchase olderkmoract/I(iI.quow nuntbrr. _.---- .----------_._- -- E C7 J a V) z x O <br /> Monthly U Weekly IJ l)uarirrly [d U c O O v ck�E Q CV <br /> Fre Log Rcgairc(I yes _ FlEguency: Other(] a - 7 = L n >. v x 1 <br /> 3 <br /> o ° 3 '-' n a ti <br /> U Z u c 3 J o y lu W V <br /> c i <br /> V1 E N N rn >• <br /> U Sa > <br /> o o � � 3 z a <br /> Santplr Localion/I>cacriplinn t)alC link n 3 3 ro <br /> Number \ S,u plyd Sampled F 7. - <br /> --- 1013- x x - - - <br /> — ---- CJ <br /> Kill 96MIM <br /> —— <br /> n <br /> F- <br /> rRcceived <br /> suhjrct to th i1i he reverse of this document <br /> - <br /> -n <br /> O <br /> — Dnir �ime 10"'30 <br /> 'r' 0 Relinqui.hed b Oate l _ Time I <br /> -- -- :-� � `I" — Date ��� -T/�me tr" ,J�./ Received hy' - Daie 'I Timeby:CCC�������� Date Time Relinquished by: Date Time <br /> lime Time Received by: Date Time <br /> COPJ'0RAIF.OFFI('F A i 4PORATORY ` OFFICE&I.ARORAIORY 11'%1111)OFFICE <br /> rr nn5 27 rn5t cn,rynat, Sura 2500 Staprcon h Road Visalia,Califnmia <br /> Santa Paula.CA 9IMJ PJ 72 �I n I Y /7 l Stockton.CA 05215 1,L(559)714 9473 <br /> Irl iROh 659 Mlq Il. (/ 'Ibl;12(19)942 0191 hlnbile-(559)7)7-2)99 <br /> rnX iRnq 575.1172 VAX:(209)942-0421 VAX(559)734 1141S <br />