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INTERNATIONAL RIA Control No 276100 <br /> TECHNOLOGY REQUEST FOR ANALYSIS <br /> CORPORATION CIC Con rot o <br /> PROJECT NAME 5 C—ajd/ DATE SAMPLES SHIPPED <br /> PROJECT NUMBER 01 7 -2- LAB DESTINATION �`�-SIS-'�� <br /> PROFIT CENTER NUMBER LABORATORY CONTACT <br /> \ <br /> v ( SEND LAB REPORT TO <br /> PROJECT MANAGER ,{- <br /> BILL TO �J Ce/ r•• —L� �'�✓' r c .n <br /> iJ <br /> r -�• DATE REPORT REQUIRED '2' <br /> Lkk <br /> PURCHASE ORDER NO T I �Gf!e __ PROJECT CONTACT <br /> PROJECT CONTACT PHONE NO J L u� 3 2" <br /> Sample No Sample Type Sample Volume Preservative Requested TesIlrW Program Special instructions <br /> J <br /> TURNAROUND TIME REQUIRED (Rush must be approved by the Laboratory Project Manager) QC LEVEL (Levels II and III subject to surcharge project specdi quiremenls must be <br /> submitted to lab before beginning work) <br /> Normal Rush ?y#✓(Subtect to rush surcharge) I II III _ Protect Specific <br /> POSSIBLE HAZARD IDENTIFICATION (Please indicate it sample(s)are hazardous materials and/or Suspected to contain high levels of hazardous substances) <br /> Skin Irritant Highly Toxic <br /> Other <br /> Non hazard Flammable (Please Specify) <br /> SAMPLE DISPOSAL (Please indicate disposition of sample following analysis Lab will charge for packing shipping archive anu disposal) <br /> Return to Client_ Disposal by Lab Archive( (Indicate number of months I _ <br /> FOR LAB USE ONLY ] �� Date/Time 22-2— <br /> Received by -IFL � �- <br />