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I Client <br /> e,\ , .v{rt r r�� Wi <br /> Address t, tejicallL'lIVllUllillCJ110liveivwiit C]L1LI1' Page of <br /> as � cr_ � 10 3440 Vine.ent Road, I leatiant H11104523 <br /> - REQUEST FOR ANALYSIS/CHWIF CUSTODY,, <br /> Q 1-- 1 Gt c /A -1 c( C Plione(510)930 9090 <br /> Contact <br /> a-,-,1 .�-[ I- -,& 4 d ^ FAX(510)930 0256 Lab Job Number 1 C jU <br /> All Contact CI, ,,o/\S Lab Destination <br /> Date Samples Shipped <br /> Address Report To Send lnv=e To Lab Contact <br /> 2 W P,�v 3 G+ ac Date Results Required 5'1 i� <br /> a��� c ��r e 5��� Pro 7 Date Report Required � f� <br /> LA7; S e S'A n AVC Client Phone No t S l y �1 � " C) <br /> "' � A o.\ C /,\ Client FAX No <br /> Q ANALYSIS <br /> Send Report Too or 2 (Circle one) 1� <br /> Client P O No 1 Client Project I D No _ t�7) _r 1 <br /> Sample Team Member(s) Al e,.\r t 1,-A r `-1 <br /> Date/ —Y No Type <br /> Lab Client Sample Air Sample <br /> Number Identification Volume Collected ed Type' Pres Cont Coni r-- a�of of Comments/Hazards <br /> Jlf� nn - 3 `� 1O65 fits V <br /> 02A-c- W Z <br /> r/1 w_ '2j , t 2 `7 X x <br /> c ll1'� AA W- <br /> Relinquished by ATE TIME Received by DATE TIME <br /> (Signature) 3 a 5 {Signature) k� / l(j a <br /> Lo <br /> Relinquished bpAT TIME Rd by + DATE TIME <br /> y � ? eceive -� <br /> (Signature) G`z fQ �/c - �/ �l 1 (Signature) <br /> Relinquished by DATE ilME Received by {) DATE TIME <br /> (Signature) (Signature) <br /> Method of Shipment 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, dtam pore size 5)Charcoal tube 6)Silica gel tube 7)Water 8)Soil 9)Bulk Sample <br /> 10)Other 11)Other <br /> COPIES WHITE JOB FILE YELLOW PROJECT FILE PINK CLIENT <br />