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zIs I R NI T1 OMIAMF O TO' M <br /> AND ANAL YSIS REQUEST DOCUMENTF—CL—WNT DETAILS <br /> SAMPLING <br /> Client V• S <br /> Sampler(s) Lt r �(,�C�CI j/] Rush Analysis 5 Days 2 Days 24 hrs <br /> Subject to surcharge <br /> Customer Numher Z� 3C.- "A.I QA/QC report required yes no <br /> Address 0Z.8 0 S• Va Y 150 <br /> Electronic.Data Transfer yes no <br /> O G A 905oZ Comp Sampler Setup Date Time <br /> 3 S3� y , t'�0 If yes To Slate Client _ Other <br /> Phone <br /> FAX �� Z s Ptntt. _ _Mlll ige Lab number n _J:53 .,_. <br /> Project name 61snr- <br /> Lab Loc SP ❑ STK ❑ VI ❑ ❑ <br /> Contact pernon <br /> Billing Information(if dtl7erent tntm alxlvz) <br /> � u _ <br /> Name L A o V u <br /> Address <br /> A o 3 0 O 0 <br /> 1 <br /> W AQ <br /> Phone T > o w a „ z 4 <br /> V c FV. to r..t+ r� <br /> FAX — U ° r° o E- rNii all 12 ", <br /> � � <br /> Contact person a ^^ A U lV Z Q <br /> m3 a " + O $ ay <br /> Purchase orderhontract/FGL quote number o ~ w Z °In W o Z <br /> Pre Log Required yeti _ no ou @ ;� ~, a O a 0 0 <br /> c <br /> a o c 3 5 V a rY' ao - <br /> aILI <br /> liqIM <br /> E u 3 G v u vy o °a <br /> o > w <br /> w u m ci s o J�J o v <br /> p o O a L. <br /> Sample I t><,,In)ttllktiutpltint Il tt� titin ?i ° s s f <br /> Number Sampled Sample! F= 4 r a. , `? s <br /> _t •taq }loo —461`44 <br /> X <br /> W i 1 ?,cp tI N <br /> OD <br /> RetlnyyiJlyd by anJ xub�uc.t io the[eimti aid cmnvlluOns on the reren u[ &' u ni <br /> nale� bi <br /> (71u. -�U0/� RJlnywxhedhy Dale TiPie <br /> Raetved by datA IJ G -nw •1 r CJ Rmcived by Date lime <br /> Relimlulshed f r Date�riitw �� Rehnqutshedby Date Time <br /> Recetvedby I IC Terre Reeelvedby Date <br /> CORPORATE OFFICE&LABORATORY OFFICE&LABORATORY FIELD OFFICE <br /> PO nor 272$53 Corporanm Stmcl 2500 Stagemach Road v1WI v Callf0mia <br /> Santa Paula CA 93061 0272 4dtikim CA 95215 <br /> Tel (8051659 0910 T[ QW)W2 018t Tel (209)734 9477 <br /> 1 A+ gn51 515 r 1 7+ I , What 2(191 737 2399 <br /> t\ IVI 11 !G <br />