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ul III Ig <br /> i1 1 Client{Tito, `uC <br /> Vo Arnxeitcniz Eizvtrotitlze*Net�voik A-E-/V <br /> 3440 Vincent Road,Pleasant Hill,CA 94523 Page*-02 of <br /> Address <br /> 1 (* �h f/�• <br /> s CFbone(510)930-9090 REQUEST FOR ANALYSIS/CHAIN OF CUSTODY <br /> i Contact RAX(510)930.0256 Lab Job Number <br /> All Contact Lab Destination <br /> Date Samples Shipped <br /> i Address Repart To Send Invoice To Lab Contact <br /> 1 <br /> 2 e 5 f trn G e 3 S�nl e Date Results Required <br /> t 3 Date Report Required <br /> R2 cn c A AS 7 7fc Client Phone Wo <br /> eonracr• q e Client FAX No <br /> Send Report To 1 or 2 (Circle one) ANALYSIS <br /> } Client P O No <br /> � Client Project E D No <br /> Sample Team Member(s) <br /> Lab Client Sample Air Dale) No Type <br /> Number Identification Volume Time Sample Pres of of Qti <br /> Collected Type Cont Cant Comments/Hazards <br /> I 2 - <br /> v <br /> I <br /> ----�_— <br /> i <br /> I` <br /> 1 <br /> { <br /> t <br /> Relinquished by DATE <br /> ............ <br /> (Signature) f �TIM r' - Recelved by DATE <br /> Relinquished PS50 <br /> nquished by (S�gnalure) T <br /> (Signature) TIM Recelv DATE TIME <br /> (Signal e) L — fie' <br /> Relinquished by DATE TIME <br /> • (Signature) Received DAT TIME <br /> Metholl of Shipment I(Signature <br /> Lab Comments <br /> 'Sample type(Specify) 1)37mm 0 Spm MCEF 2)25mm 0 a pm MCEF 3)25mm 0 4 pm polycarb filter <br /> 4)PVC filter.,diam pore size 5)Charcoal tube 6)Silica gal tube 10 Water 8)Sort g)Bulk Sample <br /> 10)Other 11)Other <br /> COPIES WHITE JOB FILE YELLOW PROJECT r1LE PINK CLIENT <br />