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-- 50u �iuoeppe oourr, Suite u <br /> Excelchem Roseville, CA 95678 CHAIN-OF-CUSTODY RECORD AND ANALYSIS REQUEST <br /> Environmental Labs Ph: 916-773-3664 Fx: 916-773-4784 <br /> Project�M^anager: Phone #: cl j/ Electronic Data Deliverables Request: <br /> /,r e �y� G �3� , . 3 '�/ -1 Global I . D .#: ���j � 7 p0� � � Email Address:"""' <br /> �l O COC #: <br /> Company/Address: Fax #: ( �� ` <br /> Location LD .#: <br /> T 7 � ANALYSIS REQUEST Pae of <br /> Project Number/P.O#: Project Name: c`°o Wet Bin#✓ llr1(?jj <br /> � T � Gur�a � LL 3 �, It 1A <br /> 0 o m Total z Due Date: <br /> Project Location: 3 & 1,1a1t��� Sampler Signature: o ui o ` 2 f <br /> u L <br /> / m w <br /> r$�✓ d� —O m v <br /> Sampling Container Method Matrix E a n o a a F <br /> Preserved y m o N N 0 h <br /> Sample <br /> y ,sa O C7 LL 0 aaND g oN <br /> Date Time a o <br /> w m w >w m <br /> J O ¢ 76 L - <br /> Fa- <br /> LAB <br /> USE EOz OF O O m ¢ <br /> > x z a > ONLY: <br /> 03 ZO <br /> Z- <br /> wo q <br /> AI2035D I <br /> Relinquish by: Date Time Received by: Remarks/Condition of Sample: <br /> elin shed by: Date Time Received by: <br /> Relinquished by: Date Time Received by Laboratory: Bill To :4 �� � <br />