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I Client ti-, ,,xs)o �,, Artier taut Ertvt►uit»ielztn atwork AEN j <br /> Page of <br /> Address r! j S„y= j oja 344(1 Vlucenl Road,Pleasant Hrll,C'A 4523 <br /> Mh�fccl <br /> Phone(510)930-9090 REQUEST FOR ANALYSIS 1 CHAIN OF CUSTODY <br /> Contact t'MTL t AX{5111}yet)U25G Lab Job Number 1 s <br /> All Contact Lab Destination <br /> Date Samples Shipped <br /> Address Report To Send Invoice To Lab Contact <br /> 2 3 Date Results Required <br /> Date Report Required <br /> n10, Client Phone No L OL--)I,—7q I`} <br /> Client FAX No 6 v 17�u1 <br /> Send Report T i 2 (Circle one) ANALYSIS <br /> Client P O No Client Project I D No <br /> / <br /> Sample Team Member(s) _ '"1c1 y <br /> �U` <br /> Lab Client Sample Air date/ Sample No Type r` <br /> Number Identification Volume Time e* Pres <br /> Collecled Type Cont Cont �` Comments/Hazards <br /> 01of of <br /> L} �'1W"U1 f)r 9� 1a4 KI l�l� -m <br /> o2A-C A6 <br /> 03A-C <br /> 05A-C <br /> Cr7A-C <br /> 013AB i I�L� 2– <br /> Relinquished <br /> Relinquished by r?5 BATE TIME Received b <br /> (Signature) GLS y DATE TIME f <br /> 6figicq Ct Z (Signature} <br /> Relinquished by DATE TIME <br /> (Signature) Received by DATE TIME <br /> (Signature) <br /> Relinquished by DATE TIME Received by DATE TIME <br /> (Signature) <br /> Method of Shipment - Lab Comments <br /> 'Sample type(Specify) 1)37mm 0 8 fim MCEF 2)25mm 0 6 um MCEF 3)25mm a 4 pm polycarb filler <br /> 4)PVC filter, dram -- pore size 5)Charcoal tube 6)Silica gel tube 7)Water 8)Soil 9)Bulk Sample <br /> 10)Other 11)Other <br /> r'nPIFG un nrr Tort nr r r 1 r'— —"' ° <br /> T mil r <br />