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I 1IRONME`�TAL CHAIN OF CUSTODY ��OPY 2 <br /> INDANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS SECTION I SAMPLING SECTION If REPORT INFORMATION SECTION III <br /> -- / I Rush Analysis(surcharge will apply): <br /> Clientl�1l11�t F"o 1c_ / elrl-�rlCf��• G/?[r� Sampler(s): <br /> ❑New Customer Customer Numbery7l'-/,� (fl ❑ 5 Day ❑ 4 Day ❑ 3 Day <br /> Address: A r ❑ 2 Day ❑ 24 hour <br /> �, Rush pre-approval by lab: <br /> C j;�� ( i r - i J / Comp Sampler Setup Date: Time: inital <br /> (� _ r ' Electronic Data Transfer: yes no <br /> Phori ��� � � ��% � �'�� me:TiMileage: <br /> ✓ // If yes,To:State_ Client Other <br /> FAX: ��-` � t ✓ —' 'C G/C�- <br /> �' ! Lab number: <br /> Project name: <br /> F't <br />_ Contact person: <br /> Billing Information(if different from above) [' a <br /> u v U <br /> Name: ° <br /> n. 4. <br /> Address: U ¢ <br /> 3 1 - 3 g _ o 0 <br /> Phone <br /> FAX: fQ N \J <br /> a !U ° N Z <br /> Contact person: o Uj } <br /> c 3 3 a - v <br /> = <br /> Purchase orderlcontract/FGL quote number: oU on z` W O <br /> U o v b = Z <br /> V a' OW 0 ; \ <br /> z ` <br /> Pre Log Required: yes no o a, Z <br /> EUc as o r v > _ f= > Vj <br /> U 3 _ o <br /> Sample Location/Description Date Time T 3 3 3 o J <br /> Number Sampled Sampled F ZFR <br /> Ail <br /> O <br /> SECTION VI <br /> CUSTODY <br /> n <br /> J <br /> E= <br /> I <br /> el�gdished by.and subject to terms an onditions on the reverse or this documentJj/�iir"1i� Date. �,`JG% Time �'<` ! Relinquished by: Date Time <br /> tReceivedb Dam Timc <br /> eceived�byf + Y�elinquishedby: / Date Time Relinquished by: Dam Timc <br /> eceived by: Date Time Received by: Date Time <br /> CORPORATE OFFICE&LABORATORY OFFICE&LABORATORY FIELD OFFICE <br /> P.O.Boz 272853 Corporation Street 2500 Stagecoach Road Visalia,Caliromia <br /> Stockton,CA 95215 Tel:(559)734-9473 <br /> Santa Paula,CA 93061-0272 i Mobile:(559)737-2399 <br /> Td:(905)659-0910 Tal:(.09)94_-0181 <br /> FAX:(805)525-3172 FAX:(2091 942-0423 FAX(559)734-8435 <br />