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UP!V 1 KOn M E`ITAL CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> ORIGINAL <br /> Client: <br /> ❑New Customer / Sampler(sl 0 G �- r,�y , / Rush Analysis subject to-surcharge): <br /> n C! tom.r Numhcr: O7L/� - --�- ---��' • ''_�[ y (• g ): <br /> Address: /�0 �F �{�U T}I 1 �j k C I -���- X15 Day a4 Day U3 Day ❑2 pay <br /> ��-?' C•IC ��� )�: -_--—_-~---` ------ - ' p ^r -u -----------'--�-- I'in-le: II' <br /> 024 hoar <br /> Flectronic Data Transter: yes no <br /> Phone: --------- tiaullleF Se,up hi: yes.To:SimeClient <br /> FAX: Other — <br /> Timc: <br /> C� <br /> Project name: / <br /> Contact G a� I�s}� Lab number: <br /> person: <br /> Billing information(if different from above) <br /> � W ' <br /> Aild1CS5' <br /> i v x <br /> Phone: o a = o a <br /> FAX_ <br /> ContactU mon ° e '_ ° f; a <br /> /p _ <br /> Purchase fvder/ccmlr-tJFGL quote numher. _ E _ n° ;:, ~ ° - W " z <br /> 4 + <br /> Pre Log Required. yes no <br /> C <br /> CL <br /> or- <br /> w � <br /> LGLl 0 <br /> Sample <br /> Number Location/Description �• T- +e <br /> Dale Time c a°. <br /> I. Samples[ Sampled E <br /> WP_ e - d E <br /> t �z 4 is X a <br /> 5 K ,� x <br /> 67 <br /> I n f ab <br /> I° <br /> . - Helinyui* y-anJ and cundiGom <br /> �'�7 crcr of Ih"r nalrr it ,`,'ry <br /> I ..`� <br /> - i1:11r / r r,,n1r <br /> _1 `� <br /> —-.�_—. R[lingLPMh 0 hy, <br /> I��'`` I I l:llr�ftiL1- rl r J3�.�fl f fat[ ilio[ <br /> L V —h In,r. lam' k..rrl,r.l i. <br /> 1 f Q <br /> 1L.- I�r, — 11x,[y�iim[ <br /> • UNU— <br /> krl,n.In1.}ItJ h5. <br /> Hnr1,-rd <br /> l ylitl'1Ik 1't'F:fIFF11'I•:R l,A IlIINA'r(1!(}, ll;ur l,nx ��— <br /> I'11 <br /> 5"",I'+x11:1.t',1'�Hk11 u'7± 14NhA'F'.K i.IItfIH 1'filHl' ❑+11[ 7im[, <br /> Irl 1\r 15,/5111'llrl � IMI til: .i. ,]i 1,....r .�/�-r .. .:,..♦.... <br />