Laserfiche WebLink
TOW <br /> �Q FOR LABORATORY USE ONLY <br /> T-, <br /> Prolect Name � - Method of Transport Sample Condition Upon Receipt <br /> 7 w7Aar Technology Walk-in ❑p p <br /> Laboratories 1 CHILLED Y0 N❑ 4 SEALED Y EI N <br /> Project# Courier ❑ <br /> 18501 E Gale Avenue,Suite 130 UPS <br /> City of Industry,CA 91748 2 HEARSPACE{VOA} Y❑ N❑ 5 OF SPLS HATCH COC Y❑ N ❑ <br /> FedEx ❑ <br /> 626-964-4032•Fax 626-964-5832 P O # ATL El 3 CONTAINER INTACT Y0 N 6 PRESERVED Y❑ NEI <br /> Company '! /lo�2G�P2lt � Address TEL ( 71Y <br /> Contact --�� <br /> Relmq s by •end c M mo © � Date City me/vim Received b State � Zip Coda <br /> FAX{ 75y <br /> Q16 � f 0 y(Signature and Prarted Nar ) Date Time <br /> Relinquished by-tsgnaiereend ed Na—? Dat Time Received by is iureeMP led ) Date Time <br /> O n <br /> Relinquished by i5igoaiure and Primed Nana} ate Time Received by (signature aea PnrA d Nem•) Date Time <br /> 1 hereby authorize ATL to perform the work Send Repo To Bill To Special InsiruClions/Commenis <br /> indicated below <br /> Attn Atte <br /> Co ._ � Co <br /> Project MgUSubmilter(Print Name) Date <br /> Address Address <br /> S nature Cit State_ZIp City State—Zip <br /> Unless otherwise Sample Archive/Disposal Circle or Add m �m CIRCLE APPROPRIATE Q A-QC <br /> requested all samples ❑ Laboratory Standard Analysis(es) m v 'V <br /> will be disposed 14 days ❑ Other Requested Ott/ o� �� my MATRIX o FITHE ❑ <br /> after reporting or ❑ Return To .° �y y a J� F RWQCB ❑ <br /> at Lab's discretion *$10 00 FEE PER HAZARDOUS SAMPLE DISPOSAL ct,}\ U�c�my y �� o m�V oQ QJ ¢ SPECIAL ❑ <br /> T� <br /> LAB USE ONLY Sample Description y cmc �o a° o w� �w ��' 2zQO v �,O a� °c ul <br /> V �O h '� Y a� p� �� Q ��Q U rn <br /> Lab No Sample I D Date Time `o`�„o"��o`� �O�Q 'Ib <br /> � \q`' 4� � Cr <br /> ops p TAT # Type REMARKS <br /> ' g <br /> CIL 4�--//9 t, � T � <br /> •TAT starts 8 a m following day if TAT A- QVernight B 1=mergency C= Critical D_ Urgent Routine Preservatives <br /> <24 lir Next wvrkda 2 Workda s - 3 Workda s ��7 Workdays <br /> samples received after 5 p mH–Hct N–Norte <br /> Container Types B=Tedlar Bag C=Canister V-VOA O=Other – <br /> DISTRIBUTION White with report, Yellow to folder,Pink to submitter <br />