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� � � � � � � !♦ � � � � � � SR <br /> m CHAIN OF CUSTODY/LABORATORY ALYSIS REQUEST FORM <br /> »o —Pant 3902 E University Dr,Suite 4•Phoenix,AZ 85034•(602)437 2001•800 695-7222 x09•FAX(602)437 5308 PAGE OF CAS Contact <br /> www caslab com <br /> PIN Project Number <br /> !A ���� � �I ANALYSIS REQUESTED(include Method Number and Container Preservative) <br /> Project aria r IF Report CC <br /> PRESERVATIVE <br /> com ddress Preservative Key <br /> �l.1Ct'rtN � rl`C� � � � �Q � � 1-NONE <br /> 2--HNO <br /> € Q-(.!� r Z U � Q nr ~~U Qrn 3 HSR <br /> 4 NaOH4 <br /> 5 Zn�ir 9 / rO Od Z 6 McOH tate <br /> Ph o e trTri / k 0 ^ p N 4 m �mIZ�j c 7 NaHSO4 <br /> 1�� 197 /006 '467 �I/1 m ��m� merry QQ �a 8 Other ACID <br /> Samplers Sl lure Samplers nted Dine �� �� Co�O� Q� I� � m �`y ALTERNREMARK ATE DESCRIPTION <br /> ■/ r` SAMPLING <br /> CLIEIJT SAMPLE ID LAS ID DATE TIME MATRIX <br /> x — 1167 JU,-• k <br /> Kilk) 11 In-0 0-04 11,11ii,14 I'qAq <br /> is lav 0 it K K <br /> A - _o� �l ►� u ivy$ t1 �' k <br /> 1 8 -11-04 r af� itL . <br /> SPECIAL INSTRUCTIONSICOMMENTS TURNAROUND REQUIREMENTS REPORT REQUIREMENTS INVOICE INFORMATION <br /> ...+ RUSH(SURCHARGES APPLY) —I Results Only <br /> STANDARD II Results+QCSummanes PO# <br /> (LCS DUP MSIMSD as required) <br /> REQUESTED FAX DATE BILLTO <br /> III Results+QC and Calibration <br /> _ ,I� Summaries <br /> kis.- <br /> P 5,, +o • + REQUESTED REPORT DATE _IV Data Validation Report with Raw Data <br /> V Spelcallzed Forms I Custom Report <br /> See QAPP p <br /> Edala _Yes _No <br /> SAMPLE RECEIPT CONDITIONICOOLER TEMP CUSTODY SEALS Y N <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY , <br /> Slgnatur Signature Stgnature Signature Signature Signature <br /> s `' t <br /> Printed Name Printed Name Primed Name Printed Name Printed Name Printed Name <br /> FIf �? Flrm Firm Arm Firm Firm <br /> Ur CI �GAVf rtfv, <br /> Dat�elT f}Jp fr� Dateflme DatalTme Datern _ Daternme DatelTme <br /> Dlslnbutlor JWNW, Return to Originator Yellow Lab Copy Pink Retained by Client SCOL-0101 06 <br />