Laserfiche WebLink
I4JVIRONMENTAL CHAIN OF CUSTODY COPY 2 <br /> AND ANALYSIS REQUEST DOCUMENT <br /> r <br /> ` Rush Analysis(surcharge will apply): <br /> Client: <br /> /y .. y �r,„ /� ie. -( G'/'I7(.-�/!f 2 ' 11< <!') (i!F'C +1C <br /> z Sampler(s): ❑ 5 Day ❑ 4 Day ❑ 3 15ay <br /> ❑New Customer Customer Number: `/G���'��' 7 ems; <br /> 1 <br /> Address: �' �� • � /^! ��J'C �� ❑ 2 Day ❑ 24 hour <br /> t _ �, � 1 •, �,,I .� c 7 t <br /> Comp Sampler Set up Date: Time: Rush pre-approval by lab: <br /> Phone: =f ° _f L� 1 r Electronic Data Transfer: yes no <br /> Time: Mileage: <br /> FAX:C J`C' 1 1 �`�"y - TG � // i / If yes,To:State_ Client Other <br /> Project name: };j.$) %.. (/' Lab number: <br /> -y <br /> Contact person �`� +'_ ( A <br /> Billing Information(if different from above) lu <br /> Name: <br /> U f <br /> a <br /> Address: <br /> 0 <br /> 3 1 3 O 3 0. 0 0 <br /> Phone' > = c D Z C <br /> U o u Y (5 n V r <br /> FAX: a f c o ¢ W j <br /> Contact person: y a D 3j3 <br /> Purchase order/contract/FGL quote number: a g o + <br /> n aW <br /> q o �_ �= o -- 3 r <br /> Pre Log Required: yes no -�� �? Z Z Z a ` <br /> o ; O N s <br /> n U c 2 3 9 3 5 v W t <br /> tell 0 <br /> Sample Lxation/Description Date Time o <br /> _3 <br /> Number Sampled Sampled f Z (- a: �?3 cq _ a a Q <br /> r <br /> 0 <br /> F- <br /> CUSTODY SECTION VI <br /> Relinquished by and subject to the terms and conditions o thercse veris document: <br /> ocuent: / <br /> � / ! <br /> ` il.• (. Date ..'1-G'Z-Time Relinquished by: / Date 1 imc <br /> Received bv:' 1/-'-'v' /�'� v/L.-( `•c Date,",) -!� Time Received by: %DateJ <br /> L t f <br /> ` ) <br /> Relinquished by: �7 V t.'2+^� %!�/• ���-(i( Date:,'-, ? C,-)-Time �q Relinquished.by: Date Time <br /> Received by: /.( / ��/�S Dare J ��//Ti— { r'./..' Received by. r Dale __Tirtx _ <br /> CORPORATE OFFICE&LABORATORY OFFICE&LABORATORY FIELD OFFICE <br /> PO.Boz 272/853 Corporation Street 2500 Sta ecoach Road <br /> rnia <br /> Santa Paula.CA 93061-0272 8 Visalia, )734-94 <br /> Stockton,CA 95215 Tcl:(559)733-9473 <br /> Tel:(805)659-0910 Tel:12'09)942-0181 <br /> Mobile:9)71 8435 99 <br /> FAX (805)525-7177 FAX:(209)942-0423 FAX(559)714 8435 <br />