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T}!E <br /> ORDER ID # ti _ _ yY ` TMNING 2527 'ESNO STREET <br /> LA900. tiT00. 1E 4 I "c FRESNO, CA 93721 v <br /> %HAINOF CUSTODY/ANALYSIS REQUEST (209) 268-7021 FAX:(209) 268-0740 <br /> REPORT TO: INVOICE TO:(OTHER THAN CLIENT) COPY REPORT (Circle One) <br /> ATTENTION: ATTENTION: State Dept. of Health (DOHS) <br /> NAME: NAME: <br /> Fresno Madera Mariposa <br /> ADDRESS: ADDRESS: <br /> Tulare Kings Merced Kern <br /> OTHER:THER: <br /> FAX: CONTRACT 1 PO # <br /> COMMENTS BACTERIOLOGICAL SAMPLES ONLY PROJECT INFO: <br /> _ PUBLIC ROUTINE <br /> SURFACE WATER REPEAT / Jr <br /> CONSTRUCTION REPLACEMENT PRJ#: <br /> OTHER OTHER MGR: <br /> PRIVATE ANALYSIS REQUESTED <br /> TURNAROUND REQUESTED: (circle one) <br /> ROUTINE - , —r "-RUSH (Specify Date): <br /> MPLED BY (PRINT NAME): _ s <br /> SIGNATURE: <br /> r <br /> TYPE KEY: Drinking Water-DW Waste Water-WW Aqueous-AQ <br /> Solid/Soil-SL Other-O )Describe in Comments) <br /> ID# SAMPLE ID SAMPLED TYPE <br /> DATE TIME <br /> — 4. <br /> L <br /> J <br /> RELINC2lfISFFED BY COMPANY DATE TIME>' : RECEIVED BY .COMPANY <br />