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IROnMEl�TAL CHAIN OF CUSTOD Co <br /> ND ANALYSIS REQUEST DOCUME <br /> ' f 14� J �= s + l r w f Rush Analysts lies Days _ 2 Days_ 24 hrs <br /> Client +/1 / Sampler(s) �l!WI . u4f[� _ _ _ Subject to surcharge <br /> Customer Number 22 <br /> Address <br /> 2 �� U t • 1 tit QA�QC report rcgDltad yes V-- - no <br /> en-{n Camp Sampler Set up Date lime State Form requiredd yea no <br /> Phone �i4 '7 7Z —7�/� — --- Time Mileage Lab number <br /> FAx � ' Z—/ t�3 <br /> C! Lab Loc SP ❑ STK ❑ VI ❑ ❑ <br /> Project name <br /> Contact person t - <br /> Billing Info ton(L dlffe t from above) <br /> u <br /> Name t SCi�c Yu �v d x g <br /> Address �r�lo�,►� o <br /> C7 3 :, O p <br /> S C� .. " O t u Z O <br /> Phone �9 !� G 3 = m <br /> FAx <br /> Contact person 1 C7 n°. c o <br /> Purchase order/contract numberbo <br /> s= a `.3 �" Z z r. <br /> 9 3 rn = x <br /> q <br /> _ r - �r � t � a+, ' i _ Y G � Ct O � 3_ p � � � � �W ;a�V ..1 �?• <br /> Sample Locationn3esenption Date Time <br /> Number Sjunpled. Sampled z s n ap <br /> t6131firl S <br /> -AA 1114 <br /> 1 r/ 1'ZI0 t S <br /> 'All <br /> e, 8S <br /> -3 G" ✓ - 5 + 5- q a <br /> IRS K11 IN <br /> b7 1 <br /> s117 <br /> OM _ , « <br /> M= 1.0J C <br /> !! YTime Relinguishedbr Due Time <br /> , Y <br /> Recti i Ti Reaelv�ed 6y Due Time <br /> RdlRui br ` „i� Date Time r Rei-011iedbr Dale Time <br /> J Rewired bir Data TTime Rece1wif by Date Time <br /> CORPORATE OFFICE dr LABORATORY OFFICE h LABORATORY FIELD OFFICE: <br /> P.O.Boa 2721833 Corporation Steeel 2500 Stiisecaadi Rad Yash; mt <br /> Caliros <br /> Sams Paa1L CA 9061-0272 7Stxklan CA 932[3 Tel (209)734 9473 <br /> Tel <br /> (803)659-0910 Tel(209)942-0191 Mobile(209)737 2399 <br /> FAX (Anil 5754177 FAX (2(i9)94241411 FAX(2(M 734-0435 <br />