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Alturas <br /> qJ'Cusimll, Record— AIM as <br /> Analytics _7_J <br /> 111C. 1282 Altm-is I)Hve, Moscow 11) 83843 (201) 883-3400 FAX 882-9246 <br /> Company Name: Project Manager: <br /> Address: Sampler Signature: 1 1 ReSt.IltS needed by: <br /> Next Day <br /> L EJ nione <br /> City: State: Zip: 2nd.Day" Abil <br /> Project Naii ie& P Q <br /> FC7 01 'i_2 Q, .Nb'�rn rat <br /> Tel: Fax: Purchase Order P: /_ I-1— <br /> E-mail <br /> 'Please call to verify rush charges <br /> E-mail: shipped Via/Other: <br /> before submillinq samples <br /> Provide Sample Description List Anal ss RequestedNote Special Instructions/Comments <br /> Please indicate Wilts to be reported <br /> E <br /> > <br /> Lab U 75. E <br /> E m <br /> ID Sample Identification Sampling Date/Time Mallix 4t <br /> Signature Printed Name; Company Date Time Lab Use Only <br /> Received Intact? �.YES NO <br /> Labels&Chain Agree? <br /> Relinquished by <br /> NO <br /> Received by Containers Sealed? Y9DS NO <br /> Relinquished by Describe <br /> Received by <br /> Relinquished by <br /> l - <br /> Received by of <br />