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CHAIN OF CUSTODY I <br /> ENVIRONMENTALCHAIN <br /> ANALYSIS REQUEST DOCUMENT ORIGINAL <br /> SAMPLING SECTION 11 <br /> y �l r\d' <br /> Rush Analysis(subject to surcharge): <br /> Client: V/1/ y� `7 f �J ' trampler(s): y ❑ 5 Day ❑ 4 Day ❑ 3 Day <br /> Q New Customer Customer Number: <br /> Address: Cod C' ❑ 2 Day LJ24 hour <br /> Comp Sampler Set up Date: Time: Electronic Data Transfer: yes no <br /> Phone: i��� S467-370 t <br /> FAX: iT` <br /> r,M"`� 3 3 z,,�6 3 Time: Mileage: If yes,To:State_ Client Other <br /> � J O <br /> Lab number: Il'JV Jl <br /> Project name: �, n <br /> Contact person: <br /> `illing Information(if different from above) <br /> Name: <br /> a p C1 z <br /> Address: _ n <br /> o <br /> z " Q <br /> Phone: <br /> • � rn M � <br /> FAX: U F 0 <br /> g br- <br /> Contact person: $ a 3 3 A U x N Z 4 > U o <br /> o � �—o � � 0. + — <br /> Purchase order/contract/FGL quote number: E tj o y v 0 8 W x W o <br /> O rY ' <br /> Pre Log Required: yes no ° v z y a z d <br /> S � � >. o � � � °a> >• <br /> � o � z 3 3 3 � h a H .. ,-, � ,� v <br /> .. <br /> E U U v .a u ai _ rz '131 <br /> (I <br /> v = — v T Fr > c�7 0 6 <br /> CIO O z ` Q n v w v <br /> y v "k <br /> o `o 0 0 ani O ,� SL G G o� U <br /> Sample LocationlDescription Date Time o 7 U <br /> Number Sampled Sampled F z F a �s v 3 ti m x 0. C ri <br /> I 1 <br /> CUSTODY SIA'l ION V1 <br /> LJ <br /> C <br /> i0 <br /> .n <br /> A <br /> F� <br /> I <br /> R ishe by and sub'ect to the terms and conditions on the reverse of this document: <br /> Relinquished by: �1 Datc Tim< <br /> Iy/ jam X 01 /•�� : S ��o **TimeeivJ6�11 <br /> Date'e% Timc t� l Receivedby. Date <br /> Relinquished by: A Date Time Relinquished by: Date Time <br /> pp �/�°J <br /> Received by: It Date �Ti me—1 Z) Received by Date Time <br /> CORPORATE OFFICE&LABORATORY OFFI��CE&LABORATORY FIELD OFFICE <br /> P.O.Box 272/853 Corporation Street ^_500 Stagecoach Road Visalia,California <br /> santavi 93061 A I r N ckton,9 I A t 1 1 2091.731 I o <br />