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CHAIN OF CUSTODY <br /> ENVIRONMENTALCHAIN <br /> ANALYSIS REQUEST DOCUMENT ORIGINAL <br /> L �r i FQAr,c, <br /> ysis S Days 2 Days 24 hrs <br /> Client Sampler(s) 1Cti! �`{ � Subject to surcharge <br /> Customer Number r port required yes no <br /> Address Data Transfer yes no <br /> Comp Sampler Setup DateTime <br /> � n,DState_ Client ,Other <br /> Phone � L g3 J -1 2-2— <br /> Time Mileage rFAX <br /> Sp ❑ STK ❑ VI ❑ ❑ <br /> Project name v� J <br /> Contact person r <br /> Billing Information(If different from above) t' J <br /> Name x <br /> Address rz 3 x 4d <br /> ?5 0 3 sd v Q J <br /> Phone <br /> FAX u ie- `� rn u x a <br /> Contact person 3^ A z <br /> Purchase order/contracvTGL quote number o v u VI <br /> a Q e 1 c� <br /> U 0i G v 5 R a Q � ! G <br /> Pre Log Required yes no = z y z Vjw[/J�� J �I <br /> J Ei <br /> yea o a N L ! CIA- I,-- <br /> Sample Location/Description Date Time <br /> Number Sampled Sampled <br /> Al -2q`kla2 3VNejW <br /> Rellnqulshcd by and subject to the terms and candiaOna on the I[Yette of This doe menl L <br /> C� <br /> Data-� r7�pV Time J `' Relingvnhcd by Dau Time <br /> Revel b Datc9'2q U 'n"J G Received by Date Time <br /> Rtttnq a dby Date Time Reiingmshed by Date �_'rtme� <br /> f <br /> Retarvedby bale Time Received by bate 7 Time 1 <br /> CORPORA C1 A LABORATORY OFF2C ORATORY FJELDOFF CE <br /> PO Bea 27 anon Street 23005u Road V4.1.a,California <br /> Sanupsula, 1-0272 Slahon IS Td (20417]!947 <br /> Tel (805)6590910 Tcl 4209) 01st Mobile (209173721 <br /> FAX (603)525 x172 FAX (2 ?19424M23 FAX('09)734 8437 <br />