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L�1 v 1 AG, AE, 1 1AL AND ANALYSIS REQUEST DOCUb EwT� � <br /> Q '1 ORIGINAL <br /> FORM W SAMPUNG SECTION 11 REPOWFINFORMXfION <br /> I -� .;' �� � ,s•� [Lab <br /> Analysis(subject to surcharge): <br /> Client: �� ' Sampler(s): �1ey� �� � � � 5 Day ❑4 Day ❑3 Day ❑2 Day 024 hour <br /> ❑New Customer Customer Number: <br /> Address: 1 �{�?�� L� ; ectronic Data Transfer: yes no <br /> 40 Comp Sampler Set up Date: �' Time: 3 pti yes,To:State_ Client Other <br /> Phone: �� l <br /> Time: Mileage: <br /> FAX: n p <br /> Project name:' Ga PQ- �[�� - number <br /> Contact person: 11 "�y tVJ W Ci �-c• 2 <br /> H `a <br /> Billing Information(if different from above) <br /> ° g o U <br /> Name: x v <br /> Address: <br /> 0 <br /> >_ <br /> Phone: :� ? o oa Vo o y V o ,O <br /> _ U N N <br /> FAX: U s� A rn d" ti <br /> v a o d b <br /> Contact person: 0 w A U N z A > j <br /> a o A a + 84 <br /> Purchase order/contract/FGL quote number: o z \� <br /> U t <br /> Pre Log Required: yes no 50 z ^' H a z O W0 c^� t <br /> o v 33 U rn 5 ti = Y <br /> a 11111111 aI�pii w g g ) rl r S ✓� C ez V <br /> W U tc� <br /> o3 <br /> c <br /> Sample Location/DescriptionDate Time <br /> Number Sampled Sampled [-� Z h a' P C7 o] oa a H U 4 <br /> I Z3 g 3 l� p <br /> C <br /> Q <br /> .n <br /> �a <br /> F <br /> SECTION1 1 <br /> Reli t.ted by and subject to the terms and conditions on the reverse of this document: Y G, <br /> Date Time Relinquished by: '• ✓� Date Time <br /> 7 f <br /> Received by: Date ( /ime '7` Received by: Date Time <br /> Relinquished by:, Date r •ime -2 Relinquished by: Date Time <br /> Received b ( S' U <br /> y: Date Time Received by: Date Time <br /> CORPORATE OFFICE&LABORATORY OFFICE&LABORATOOR]' E'I FIELD OFFICE <br /> P.O.Box 272/853 Corporation Street 2500 Stagecoach Road 1;,„,�„e -' Visalia,California <br /> Santa Paula.CA 93061-0272 Stockton,CA 95215 Tel:(209)734-9473 <br /> Tel:(805)659-0910 Tel:(209)942-0181 Mobile:(209)737-2399 <br /> t:ev M51 ao144171 FAX:(2091942.0423 FAX(209)734-8435 <br />