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ITH-EMFRY COMPANY I CHAIN OF CUSTOD <br /> Fud SmsEe Independent Testing l.ilwrrarory 1'SluhliShed IWI)4 ANALYSIS REQUEST <br /> 781 East Washington Boulevard • Las Angeles California 90021 • (21 )749 3411 • Fax (213)745 6372 �_ � <br /> P O Box 880550 Hunter's Point Shipyard Bldg 114 • San Francisco Calrfnrnla 94188 • (411)3303000 • Fax (415)822 5864 PATE PAGE OF <br /> 5427 East La Palma Avenue • Anaheim California 92807 • (11P693 1026 • Fax (714)693 1034 FILE NO"IZ 5 i LAB NO WI6 /3 Z 9 O/ <br /> CLIENT NAME 7 L O ANALYSES REQUESTED. REMARKS. <br /> PROJECT NAME. PROJECT NO /7 PO N04 <br /> ADDRESS } <br /> ❑ �yb 353I`� 2-5 <br /> PROJECT MANAGER. 141 Ch 4rL COS 9 PHONE# FAX# W <br /> SAMPLER NAME E UGZWf() (Printed) <br /> MSA/ <br /> Q � � <br /> TAT(Analytical Tum Around Time) 0-Same Day, 1 =24 Hour, 2-48 Hour, (Etc) a m <br /> CONTAINER TYPES 8=Brass,G=Glass,P=Plastic,V=Voa Vial,0=Other <br /> SAMPLE DATE TIME MATRIX CONTAINER F.0 "r SAMPLE CONDMONI <br /> NO SAMPLED SAMPLED SAMPLE DESCRIPTION wAUR K& BLWU aTMe TAT r TYPE COMMENTS- <br /> AWA 9.7.44 42:10 2• V <br /> Aw 6.7•1y z V x <br /> 10 <br /> 'P 67.94 7. oa 2 V <br /> a ' <br /> Retinqu ,eY( and Prwded llama) Received B IS�gnature and Printed Name► Pala Tim SAMPLE DISPOSITION <br /> e ; ' E—,X 40� I 1 Samples returned to client? YES NO <br /> ReivyquaW By I e end Printed Name) Race By( atu Time <br /> and tad Name L- <br /> +�4 tf ,t, 6 f, is� b 1606 2 Samples Ionil not be stored over 30 days,unless <br />' additional storage time is requested <br /> lie4nquished 9y(Spnatura end Pruned Name) Re ived By ISignasure and Pointed Name► l7 Time g G <br /> r <br /> SPECIAL INSTRUCTIONS3 Storage time requested days <br /> 18y, Date <br /> DISTRIBUTION WHITE,YELLOW, PINK TO SECO--GOLD TO CLIENT <br />