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yM� sit ENVIRONMENTAL (,t AIN UP UU31 UVI ORIGINAL <br />AND ANALYSIS REQUEST DOCUMENT <br />Client aA;�El <br />New Customer Customer Number. <br />Address: 1 65-'57j t e <br />Phone: <br />FAX: �' a e+ 5—TcseS <br />Project name: <br />Contact person: <br />Billing Information (if different from above) <br />Name: <br />Address: <br />Phone: <br />FAX: <br />Contact person: <br />Purchase order/contract/FGL quote number: <br />Pre Log Required: yes Frequency: Monthly 0 Weekly Q Quarterly a <br />Other _ <br />SampleI Location/Description <br />Number <br />t: 3 /-1 ✓1 7F - <br />Tel: (805) 659-0910 <br />FAX: (805) 5254172 <br />Date <br />Time <br />ampled <br />WD <br />V('b <br />Sampler (s) : <br />Comp Sampler Set up Date: rime: <br />Time: Mileage: <br />Shipping Charge: Pickup Charge: <br />Rush Analysis (surcharge will apply): <br />❑ 5 Day ❑ 4 Day ❑ 3 Day <br />❑ 2 Day ❑ 24 hour <br />Rush pre -approval by lab: <br />inial <br />Electronic Data Transfer- yes no <br />If yes, To: State Other <br />Lab number <br />.d <br />E' <br />'a <br />CL. <br />� <br />U <br />A <br />O <br />u <br />41 <br />3 <br />4 <br />o: <br />ca <br />� <br />e <br />0 <br />® <br />s` <br />3 ,� � <br />0' <br />3 <br />x <br />o <br />a <br />a <br />x <br />O <br />s 3 <br />0 <br />„ <br />z v <br />{�JJ <br />>0 <br />o <br />O <br />L <br />O <br />n <br />v N C4 L1 <br />a <br />�t-�ch <br />rn <br />a <br />¢ N (4 J <br />a. <br />a <br />oto <br />Q <br />a <br />N Z i4 <br />o. <br />o <br />li <br />+ W <br />0 <br />z <br />� <br />S <br />9 <br />z 0 <br />t? <br />v <br />a <br />C <br />3 <br />to <br />�' <br />h <br />O <br />ev <br />/W <br />x ori < V <br />J <br />U <br />c <br />•� <br />2 <br />9 3 <br />c u <br />t7 <br />..� <br />y <br />u <br />H <br />v Uj 0 <br />N w <br />�.. <br />o <br />y <br />u <br />� <br />r'n U 3 <br />_ <br />' <br />o <br />� <br />•ia OQ <br />0. <br />En° <br />3 <br />tn° <br />u <br />E' <br />Z <br />FT <br />a <br />H 3 <br />on <br />KC1HH l 1 y{in SU6JGct to Ih erns and conditions on the reverse of m <br />is document: <br />\i\ p//P=i Time -1 mquished by: <br />Received Y Date - J TiaK_ <br />R by: <br />Reh by: Date Time di <br />Received b . Date Time tr..,•.: L <br />Z= Stagecoach Road <br />Stockton, CA 95215 <br />Tet:: (209) 942-0181 <br />U <br />Visalia. California <br />Tel: (559) 7W-9473 <br />Mobile: (559) 737-2399 <br />Time <br />