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ENVIRONMENTAL CHAIN OF CUSTOD Y <br /> ORIGINAL <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS SECTION I SAMPLING REPORT INFORMATION <br /> ..__ ��� � �� � � Rush Analysis(surcharge will apply): <br /> Clienr�S�N�L�. L�:(!./ClK�iUG LHCl _l+i'1� • Sampler(s): ❑ S Day ❑ 4 Day ❑ 3 Day <br /> ❑New Customer Customer Number <br /> Add r 5s: El ❑ 2 Day ❑ 24 hour <br /> v Comp Sampler Set up Date: Time: Rush pre-approval by lab: tnital <br /> Phon O , g �'7J �/�/ Electronic Data Transfer: yes no <br /> Time: 'Mileage: <br /> FAX: 6 "— d�� If yes,To:State C' nt Other <br /> Lab number <br /> Project name: / <br /> Contact person: <br /> illing Information(if different from above) t— a u <br /> A <br /> u u 7 (� <br /> ame: x <br /> Address: <br /> Ca `u <br /> >j 3 y 3 O O <br /> O0 ,`� 3 <br /> Phone: U o °' <br /> O n - F-' N <br /> FAX: c� F o Q n° o c r' EW <br /> Contact person: o o 3 m 3 U N Z rrj <br /> E � �o o , - a_ + <br /> Purchase order,'contract/FGL quote number: o U c � z F x <br /> O <br /> Pre Log Required: yes no °6 '� v Z J � C 73 <br /> z w 1 N <br /> n <br /> SAMPLE INFORMATION F U 9 > u F=75 0 > w �• �r <br /> Sample Location/Description Date Time n 3 3 Z <br /> Number Sampled Sampled <br /> si <br /> 3.� x <br /> 2 .cb i <br /> 1* V <br /> Q <br /> 0 <br /> Relin i.. by mb}cl emu n nditions on the reverse of this docum t: ` <br /> / 1 <br /> DatQr%� Time Relinquished bv::. Date Time <br /> 1 m_� <br /> R ce 'e Date vC�+ e%%lZ Received by: �, Date Time <br /> in ed y: I Dale Tirnc Relinquished by: Dale Tina <br /> Da i _ _ Recci,,d bv: <br /> CORPOR/ rICE R LABORATORY IVFfCF BORATORY FIELD OFFICE ' <br /> P.O.Boz 2'. DWralion Street 2500 St Road Visalia,Califomia <br /> Santa Paula, J61-0272_ Stockton IS Tl:(559)734-9473 J ' <br /> Tel:(805)659-u910 Tel:(209)9r1--6181 Mobile:(559)737-235 <br /> FAX (sm)525 117'_ FAX:(209)942-nt21 FAX(559)714.8435 <br />