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ENVIRONMENTAL CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT ORIGINAL <br /> =9211W �Izlul <br /> Client �.. _ !! Rush Anal sis 5 Des 2 Da s 24 hrs <br /> �1 L1'!�N Y Y Y <br /> 7 Sampler(s) Subject to surcharge <br /> Customer Number r �J <br /> Address QA1QC report required yes no <br /> Electronic Data Transfer yes no <br /> a� f p Comp Sampler Set up Date Time <br /> Phone . _��.L•� �—�I O If yes,To State_ Client Other <br /> FAX Time Mileage Lab number U li , ' <br /> Protect name <br /> S o r"c-CcJ 1 E:� S U El C I-- Lab Loc SP ❑ STK ❑ VI ❑ ❑ <br /> Contact person ffilanric., aj2rr— <br /> Billing Information(if different from above) <br /> Name 0 (� <br /> Address <br /> ba o v 196 t s x <br /> Phone ° <br /> FAX <br /> t� a� <br /> u <br /> Contact person y p <br /> oa + v <br /> Purchase order/contract/FGL quote number S 0 — a C x S ,i 1 <br /> to O , 5 Q f <br /> Pro Log Required yes no ,a v Z y S G coro f <br /> 3 3 v>1 oLJ <br /> 'ti! 77 <br /> 4 �1 <br /> Sample Locauon/Descnption Date 'rimee u <br /> Number Sampled Sampled z — a1 m <br /> Relinquished by and subject io the temu and conditions on the reverse of ibis doe m�efns(77, r� <br /> Date[�)74- u Time l" 5 ReLngmshed6y Dale 'lime <br /> Racm b cJ P5 Date-f-4 '1 g Time f� Received by Ante Time <br /> Rellnq by Dau 'time Relinqutthedby Due lime <br /> r Received by Date 'fine Racrved by Dale `ne <br /> CORPORATE OFFICE 8 LABORATORY OFFICE A LABORATORYELD O C/E <br /> PO Sax 2721833 C on Street 2300 Sugccoach Yiss,liti Califomla <br /> Santa Paula,CA 9 ^[o k,:CA 95 Tcl (2 734 9173 <br /> i Tel(8031 639 091 Tet(204)912 0 Mobile(209)737 2399 <br /> FAX (905)52541 FAX(209)942 FAX(209)7348435 <br />