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ENVIRONMENTAL CHAIN OF CUSTODY ORIGINAL <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENI' DETAILS <br /> / /„1 W Rush Analysis(surcharge will apply): <br /> Client: �i L/� / Z 1V��+ Sampler(s): ❑ S Day ❑ 4 Day ❑ 3 Day <br /> ❑New Customer Customer Number: d 4. CA - <br /> Address: 6 3 Z :5, A'/ 1.* to 'S T ❑ 2 Day ❑ 24 hour <br /> 01 � �� qb,' Comp Sampler Set up Date: Time: Rush pre-approval by lab: mmlal <br /> Phone: ��7 Electronic Data Transfer: yes no <br /> ��/ Time: Mileage: <br /> FAX: `�Y O/0 If yes,To:State___Tit Other <br /> Project name: <br /> /�� At of Q� � � � Lab number: <br /> ___Tit <br /> Contact person: Oise FPS Xt 5 g <br /> illing Information(if different from above) F a, <br /> tl U <br /> ame: a U <br /> Address: <br /> < <br /> U O 3 = o In. C) 0 <br /> > 3 O 3 Z <br /> Phone: <br /> U v r <br /> u _ O Q <br /> FAX: U <br /> v ca a, <br /> Contact person: o a 3 3 U N Z <br /> lu <br /> n N o � Fo n y a. + W <br /> Purchase ordedcontract/FGL quote number: E In x ° ►`� <br /> q U v U p cz E W r d <br /> Pre Log Required: yes no .� USample <br /> Z = a z O <br /> a o =c z 3 3 7i U <br /> v O <br /> 10 K-11 W fill I <br /> tEj <br /> Location/Description Date Time n E <i a 3 " u U <br /> Number Sampled Sampled F' <br /> Z41/ <br /> •dL l <br /> - <br /> 1A W rilly 9.4 CUSTODY SI CI 10.\ I <br /> .� <br /> F <br /> Re`linquished�byya�n�d�subjec�t toJthc t/c rtns and conditions o the r�cyrs'cp(�p( is documene <br /> ` ti"D7teG�� Time Relinquished by: Date lime <br /> ��- Received by: JIAO -• e d DUte Time Received ate /l Time <br /> F7, Relinquished by: 0 , �� Dalc&t: O�+T me Relinquishe y: Time/'L-/�I(y�-��j\J� <br /> 1 <br /> Received by: WI Time,_,,51.aYJ Received by: Time <br /> CORPOP -VICE h LABORATORY OFFir 'BORATORY W,(, <br /> OFFIC <br /> P.O.Boa: rporalion Street \ � j �'f 2500! Roa a i (rSantaPaul, 01-0272Stocka. _ 9)7d7Tel:(ROS)65Y-tnlU , I n`1�(J ` �jel:}09 IIRI (559)937-2395 <br /> FAX:(805)525-[172 1 `�`/�t��1�S� J�•. (/ `(1`�Il �2 .t_ ,.l <br /> FAX(559)734-8435 <br />