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ENVIRONMENTAL CHAIN OF CUSTODY ORIGINAL <br /> V AND ANALYSIS REQUEST DOCUMENT <br /> Client _ �.t/r�e �lJ�, / O, c , $ Rush Analysis 5 Days 2 Days 24 hrs <br /> Sampler(s) t �7 Subject to surcharge <br /> Customer Number 3—�� --_ QA/QC report required yes no <br /> Address _ �0 ' �7 X �� <br /> Electronic Data Transfer yes no <br /> �r Comp Sampler Set up Date Time If yes,To State Cilent Other <br /> Phone 1 O U .3.r. >��l�l � ��� <br /> Time ��Oe..�' Mileage Lab number <br /> ,722 <br /> FAX �6 s �� 6 .�>� y -- � --- <br /> Lab Loc sp ❑ STK ❑ VI ❑ ❑ <br /> Project name <br /> Contact person <br /> Billing Information(if different from above) a°c <br /> CU 1 <br /> Name <br /> x v y aa`0 <br /> Address <br /> C7 O 3 s` a 0 0 � <br /> Phone 0 <br /> a q C <br /> FAX A <br /> Contact person p^paa Q v U N z W V v U <br /> Purchase order/contract/FGL quote number tj o Q m `Q I z <br /> Pre Log Required yes no O z r Z z G <br /> eu <br /> v !\ C C0.0 <br /> SAMPLE.'INFORMATION sl:CTION IVu a rn > = F w G G r; <br /> Sample Location/Description Date Time 0. 3 x�i x a v <br /> Number Sampled Sampled z ��' s c� W <br /> zy- az / 2 z <br /> Rdingutshed by sn to to a temts and condutons on the reverse of this documetnntt <br /> 7T //Time Relin9wsi,ed by Date `-Time <br /> t <br /> J� 2r <br /> a � a �n `�"� t�•+y� ' ,_.R Idved�Y S Time�:l,!� Recnved by t/ �1 ADa4 <br /> te�� Time <br /> yxs. r� J �ti7'./• y� �-, 3� t.1 f vi l ),C/ Aha <br /> ?&ICIVt oate�A 1 rime Relinquished Date Time <br /> y,h L% c wr F_ Raaved 6y Dal Time Received by Dale Timc <br /> CORPORATE OFFICE&LWOOKATORY OFFICE R LABORATORY FIELD OFFICE <br /> PO Box 272!853 C tion sheet 250D Stagecoach Road Visalia Cahrornta <br /> Santa Paula CA 9 2 Stockton CA 952 OCT �]Q Tel (209)734 9473 <br /> 3 FAX((805525-41 FAX (209)942_0 <br /> C 2 2 1998 FAX=(20934-8435 46 <br />