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Roporling Informnlion <br /> 1. Client ,, Alnei ictal L'nver onmenful Network AEN Page S- of G <br /> Address 3440 Vincent Road, Pleaunt Hill,CA 94523 REQUEST FOR ANALYSIS 1 CHAIN OF CUSTODY <br /> [ Phone(510)930-9090 <br /> Contact FAX(510)930-0256 Lab Job Number <br /> All Contact Lab Destination <br /> Date Samples Shipped <br /> Address Report To Send Invoice To Lab Contact <br /> 2 r Date Results Required <br /> Date Report Required <br /> Client Phone No <br /> Client F X No <br /> r� % C O O � <br /> Send Report To 1 o2 Circle one) <br /> ANALYSIS <br /> Client P O No Client Project I D No �\ <br /> of <br /> Sample Team Member(s) ".1k Cz <br /> Lab Client SampleAlr Date/ Sample No Type <br /> Number Identification Volume T'me -hype. Pres of a <br /> Collected Cont Cont Comments/Hazards <br /> <: r - <br /> c 2 f' � G <br /> O' <br /> C — � <br /> O - 22 ' <br /> C/ I7 30 <br /> z2 9f1 r <br /> Relinquished DTE TIME Received by TE, /' TIME <br /> (Signature) (Signature) <br /> Relinquished by DATE TIME Received ATE TIME <br /> (Signature) 5 � (Signature) <br /> 13 <br /> Relinquished y DATE TWAE Received by DATE TIME <br /> (Signature) (Signature) <br /> Method of Ship"noit Lab Comments <br /> 'Sample type(Specify) 1)37mm 0 8 pm MCEF 2)25mm 0 8 pm MCEF 3)25mm 0 4 pm polycarb filter <br /> 4)PVC filter, diam pore size 5)Charcoa f)Silica gel tube 7)Water 8)Soil 9)Bulk Sample <br /> 10 Other <br /> M M M wwll� M -- Ther_ - = M M M M <br />