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( 1 I Ht I VVIIVIWU LAbUHAI UHIES, 1114U. I'lulect wanie i ' t + i J <br /> 2527 Fresno.Street, Fresno, CA 93721 Address _�UU / Al /4l0r <br /> (209) 268-7021 <br /> Date Bch aln-of-Custody and Analysis Request Record Mgr. TL# <br /> Page of T <br /> Analysis Requested <br /> Report To: Copies To: Nc C ; / -.► <br /> 1 ( Lays,1'­ <br /> Client Name { r•-,J -'rr i <br /> v - <br /> Address �s _ ,,••bU�,•.; <br /> Expected Turnaround: ' ' ' ' '':�:'1• f`, + <br /> Contact Name 4.ii L •� T O Elr. .i•� '• <br /> Rush Routine MAY:� 1A ''5: 1991 <br /> Phone <br /> Contract/PON Specify Time t <br /> i Sampler Name <br /> (Print) O FAX# I t t l <br /> ^h Client SampPle. Semple <br /> Sample ID Date/Tlnie T e #/Size/type of Contaidof <br /> l Yp i'fIl9lirli�}�IifFl® �i <br /> :.t!�f�.L Y• L t r <br /> -;. r. ltd';:•i; 3 <br /> .�+:r;.'`:':',t'•:�i�,i�g1;•1 1�; ,•;,, t.{+.::(?'.f��.a�}''���-�C*��K�.�rl+jy:�i^.. <br /> ,' i? 'Y•t1i �•�,7 -. .,•+;•. SQ.: •q sf Jt.t"'�r<a -�:.�M'avi M7�"+:1. t } <br /> ., <br /> .3 <br /> j i y�5�• v i yy.. t" a.- <br /> • +�:.}'• ..•?';�`Ij':,�",•:r"i..�i`(� �4Y!•:. 5�.��#L�'?;: �'sQ�'ti`�fi`••'S;'"'1�i.•`.j!,.•-{C: <br /> 4,7 •-v;1 '�1a�3 J It.'+ n t: ,.. ti:, r•'t' - .•: <br /> ,,. •; :7' +i,•,.< ••k' r g'+L'� i' • '..4•• -:+'i.t,d:Yft✓7_. <br /> V. <br /> Each hazardous sample submitted For Water samples,please Comments:(BILL TO IF OTHER') bApt. Initials' .'' l)stertitne. 'Locdtldti =.s. <br /> for analysis will be charged a hazard- check one of the following: 80i, ( " <br /> ous waste disposal fee. Clients that ❑Drinking Water <br /> retrieve hazardous samples within 30 O Waste Water 80� <br /> days of the analytical report date Will 0 Ground Water(wells) <br /> be refunded any disposal fees. O Surface Water(rivers,lakes) <br /> Relinquished py: ? ;'%%' Delivered By: Received , j pecdlded hy:, ' <br /> Signature {'�,�. ti Signature SignatUre l SlgnatUrd <br /> Printed'_ �t� Printed — <br /> ---f�� �. Company CvMpany _ �1 <br /> Company Company Date/Tlm6 Date/Time /�c� 11► <br /> . .pate/Time i-: Date/Time • • <br /> Log In Date/Time Log In balelTime _ 4L <br />