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Snlrr)►-h;nlr:uv COMPANY <br />CHAIN OF CUSTODY AND <br />�• <br />the drsrn•Ice r,l l-pou -1 it 7*(•.,t;rrg bibotatru,•• E'%lu rrr.,rled If 90-1 <br />781 l::llt W;I%hiuglllll BOUIL•V:Irtl • Los Angeles. California 90021 • 0130-19-3-111 0 Fax: ( I �) 7.15-6372 <br />' NA YSIS REQUEST <br />/ l �/ 4 '' <br />DATE:_ PAGE OF <br />P.O. Ru.x X8(1550, l lwuer's Point Shi 1 ltd IIID •. 114 • Sall Francisco, Califinnia )4188 . <br />f Y: 6 bl t 5) <br />5427 La Palma • Anaheim. Calilornia 92X07 • 14) <br />330-3nuu • rax: (•115) x_ / <br />22-5864 1 /) <br />693-1026 • Pax: 693-103- �7 Y )FILE <br />Bast Avennc (7 <br />CLIENT NAME:�. <br />(714) NO. LAD NO. <br />ANALYSES REQUESTED: <br />;RJEMiARKS: <br />PROJECT NAME: �_ . _ ¢ �� J r—� pl PROJECT NO. P.O. N0. <br />�� <br />(i: �;� • r`''I' ' <br />SS: <br />ADDRE �f.�,/: <br />tr �(�-1 <br />r <br />❑V. <br />PROJECT MANAGER: ) % �1�FJ PHONE #t: r-/ r/c; `;FAX 0: <br />LLI <br />/- r7 <br />r <br />I-I3 <br />— <br />SAMPLER NAME: <br />'r IPrN uh /,• l t� (Signature) /, f <br />✓'�/.(/1 <br />% r <br />TAT (Analytical Turn Around Time) 0 = Same Day; 1 = 24 Hour; 2 = 48 Hour; (Etc.) l <br />Q m <br />o <br />if f <br />(D <br />CD <br />Ln <br />CONTAINER TYPES: B= Brass, G =Glass, P = Plastic, V = Voa Vial, 0 = Other: <br />N <br />co_ <br />SAMPLE DATE TIME MATRIX <br />CONTAINER GO co <br />x f �� <br />SAMPLE CONDITION/ <br />NO. SAMPLED SAMPLED SAMPLE DESCRIPTION WATEn SOIL SLUDGE DTIIEn <br />TAT ` TYPE <br />COMMENTS: <br />� <br />( <br />l <br />4,0 <br />Re1,n\Isyi{:d By: (Slgnaturo and tinted Name( it Beceived y: I natluo a1nd Prin}Vd Name( <br />i <br />Data: Time: <br />Q 1 — <br />SAMPLE DISPOSITION• <br />i- <br />ANO� <br />_ ,:,�' ! l ? (,i r • /, / I .r ., Y 1 rr /i P1 <br />//Ei <br />/r') <br />1. Samples returned to client? <br />2. Samples will not be stored <br />YES <br />over 30 days, unless <br />Ilelmqul�bed By. (Signature and Priuted Name) Received Oy: (Signeime and Printed Name( :ne Tinto: <br />' ;' <br />' <br />1 <br />additional storage time is requested. <br />Rellnqui stied 9y: (Signature and Primed Narnel Received By: (signature arid Printed Name) Date: Thine: <br />3,"Sl rage time/req ested: days <br />/ <br />SPECIAL INSTRUCTIONS: <br />BY''}-tr-=-f�fff--- �r 11,L�;yt— <br />Dale <br />DISTRIBUTION: WHITE, YELLOW, PINK TO SECO — GOLD TO CLIENT / <br />I <br />