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i <br /> &solu <br /> �of CHAIN OF CUSTODYILABORATORY ANALYSIS REQUEST FORM S111, xn 4o l oql <br /> Servlceg .�7 <br /> A^Employ 3902^y 3902 E University Dr,Suite 4•Phoenix,AZ 85034 a(602)437 2001 800 695 7222 x09•FAX(602)437-5308 PAGE Z— OF GAS Contact 4 <br /> www caslab tom <br /> 4 <br /> A;!�d. <br /> Prolact Number <br /> ANALYSIS REQUESTED(include Method Number and Container Preservative) <br /> Prolec ana r Report CC PRESERVATIVE <br /> Co n ddress Preservative Key <br /> N E <br /> z CV Fmv 1 CL <br /> �� �rytl pF.. LpfV Q 7r 3 H2Sa4 <br /> m' 4 <br /> � ��I� �� 4 5 Zn Zn Acetate <br /> r ri �p a ,_nr Q 6 McOH <br /> PhqkX# O 7 NaHSO4 <br /> m � 8 Other ACIDIDL fx& Voq)#67 Ilj ra <br /> Sampler Sampnnted a j <br /> &AZ <br /> Al <br /> +� �p <br /> REMARKS/wrlm�N �p�V Q2U �� �� ca v �my ALTERNATE DESCRIPTION <br /> SAMPLING <br /> CLIE11T SAMPL ID LAB ID DATE TIME MATRIX �/ <br /> P167 -1 �'C3 k <br /> 0-04 it k �' <br /> .. 0� 1340 . 14 x <br /> -- 1—� �� k <br /> RIQ 81A&Jr, <br /> SPECIAL INSTRUCTIONS/COMMENTS - TURNAROUND REQUIREMENTS REPORT REQUIREMENTS INVOICE INFORMATION <br /> RUSH(SURCHARGES APPLY) —I Results.Only <br /> TANDARD —)44I Resufts+QCSummanes Pow <br /> j�l n REQUESTED FAX DATE (LCS DUP MSIMSD as required) <br /> III Results+QC and Calibration BILLTO <br /> (�,F RSummanes <br /> jWI �Gp REQUESTED REPORT DATE IV Data Validation Report with Raw Data <br /> See QAPP p <br /> V Spelcallzed Forms I Custom Report <br /> SAMPLE RECEIPT CONDITION/COOLER TEMP .�'+ Edata _Yes _No <br /> CUSTODY SEALS Y N <br /> RELINQUISHED BY RECEIVED BI� RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY <br /> Slgnatu Slgnatu V Signature Signature Signature Signature <br /> Printed Name //���tt���� Printed N n H)< Printed Name Printed Name Pnnted Name Printed Name <br /> Fi �.i S V fn V4,�t1 Firm 14 ` >q 09 Finn Firm Firm Firm <br /> Data ' Daum Date/Time a4er7me DatalTime DateRme <br /> Distnb ho White um to Originator Yellow Lab Copy Pink Retained by Client OC o5 <br />