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19V I RO N M ENTAL CHAIN OF CUSTODY ORIGINAL <br /> AND ANALYSIS REQUEST DOCUMENT <br /> INFORMATIONSAMPLING SECTION Il REPORT <br /> Rush Analysis(surcharge will apply): <br /> Client'/ '7s�k4 �. !UG L1.�J• � ' Sampler(s): ❑ 5 Day ❑ 4 Day ❑ 3 Day, <br /> 0 New Customer Customer Numberb i <br /> 3 Z .<__ �,Dor�� ls-� a ID 2 Day ❑ 24 hour <br /> Addr s <br /> Comp Sampler Set up Date: Time: Rush pre approval by lab: <br /> mitil <br /> Phon O /� Electronic Data Transfer: yes no <br /> d/O Time: Mileage: <br /> FAX: If yes,To:State C' nt Other <br /> / Lab number <br /> Project name: 1161111111 :V11! <br /> —eon=perso . a <br /> Billing Information(if different from above) x <br /> Name: ° S <br /> 4' a <br /> Address: 0V O 3 F a 0 0 <br /> > 3 y o a <br /> Phone: CJ 3 F. <br /> ?� E Oy � o <br /> t—' V N �V <br /> FAX: a t` o V, o g E. <br /> V N Z � V V <br /> Contact person: o 3 m 3 r � <br /> a + W <br /> E a° ° v i \ <br /> Purchase ordedcontract/FGL quote number. o v e Z j O r Q 1 N N ° z ° w V Y <br /> Pre Log Required: yes no O <br /> Ec Z V <br /> U Ea <br /> SAMPLE 1 <br /> w t3 a r- V) a <br /> o _ <br /> z <br /> Sample Location/Descri tion Date Time <br /> Number p Sampled Sampled E-- <br /> ltrio <br /> V_ lkL <br /> C <br /> A <br /> J <br /> F= <br /> R cl, b sub a enns n nditions on the reverse of this doou c <br /> Uat r7^ Time - fi Relinquished b�:.: -� Dwc Tinx <br /> R cc �c >y � Uax �iax � RecnveJ by: � Date Time <br /> mqurs,J y Dat, TV Rchnqulshed by. Datc <br /> RcrnrrJ by Da i Rccc—d by. Dmc Tmx <br /> F CF:6 .ARORATORV FIELD OFFICE ' <br /> CORPORATE OFFICE 3 LABORATORY Visaba.Cablornu <br /> PO,Box 77:/833 Corp+ntwn Sv7500 StaQccouch RoaJ <br /> eet Tel:(559)1349473 <br /> Sanu Pa ula.CA91(161A?7? Stale Lton,CA 93'_IS Alnhil, t55l)1717.11. z ?49 <br /> �.. 1 r. •nat oin,. <br />