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CHA N OF CUSTODY <br />c t RN TIRONMENTAL AIVDANALYSIS REQUEST nOCUbIENT <br />� 1.1 1 V — ' <br />Sampte <br />n Numbe <br />.a <br />z <br />-SA ' :'hPr <br />9 <br />Clitni: <br />Customer Number: <br />R<r<i�cd by: <br />Q New Customer <br />O <br />Tir•.e� 7 <br />Address: <br />N I <br />R:.ernd by — <br />Sr�i,c}L-HJT G�. 9201 <br />256D Slae—h Rmd <br />$mob <br />u . <br />_• <br />Phone: <br />b <br />lu4JPS —3z -lb <br />FAA: i2R7! 9421=?i <br />FAX: <br />� <br />� t"Za�•4 �.Zui� <br />T•CYtGIY-a <br />Project Dame: .g <br />g <br />a <br />Q <br />Contael petsuit:-- <br />Selling lofomtahon (if di fe3ral rtoro above) <br />Name: <br />Address: <br />z <br />—_ <br />3 <br />Phone <br />a <br />FAX: <br />< <br />z� <br />W <br />Contact person. <br />F0 <br />a <br />purchase order/contractl�GL quote number. -�'L►iat <br />— r�ti�l—t <br />httmtNY O weesiy ❑ QaanerlY <br />G'^ <br />Pre Log Required: yes Frequency: <br />Omea 0 <br />Sampte <br />n Numbe <br />.a <br />z <br />Rt3inqui.ho5 tr.. <br />9 <br />'Gmc ( 53 i� <br />R<r<i�cd by: <br />n <br />O <br />Tir•.e� 7 <br />ti <br />N I <br />R:.ernd by — <br />O <br />R <br />LocaliorJDescriptigrt <br />Date J Time <br />U <br />a{ <br />�Q i AdingOi ed DY and whiea to the u <br />Receiv t o7` <br />Rrlin7.»:had br: <br />� � � a V.O. Bos 27b453 CorCxs:ion Suva <br />� Sam. Ptaaa, C.493061 J!7? <br />i Td: (a03) 659-0910 <br />1 F.4X: ItY3St 525.172 <br />Comp Sample Set up Darr- Time: <br />Time: klileage: <br />Shipping Charge'- - pickup Ch2uge- <br />m foe nearest of 'his ®sumer- ` <br />"J <br />Rt3inqui.ho5 tr.. <br />9 <br />'Gmc ( 53 i� <br />R<r<i�cd by: <br />oxt G i <br />_ <br />Tir•.e� 7 <br />Rrlinqui=dal tn•:° <br />,.� Un:t Lm ?,;✓w} <br />R:.ernd by — <br />� <br />256D Slae—h Rmd <br />A. <br />1 <br />rL <br />u . <br />_• <br />7r1-4204)941 Mat <br />FAA: i2R7! 9421=?i <br />m3 <br />u <br />a. <br />g <br />a <br />Q <br />U <br />—_ <br />3 <br />< <br />a O <br />F0 <br />... >S• <br />0 <br />0 <br />x;30 <br />nazi <br />®r <br />a <br />== <br />$ < <C, <br />2 <br />t' <br />ci <br />N <br />15- <br />C4 <br />rn <br />43 <br />S <br />c <br />s <br />Z 3 3 <br />vi <br />v <br />G, <br />a <br />0 <br />U <br />Cj <br />E <br />a <br />d <br />z <br />O <br />- <br />G •n O <br />m foe nearest of 'his ®sumer- ` <br />"J <br />Rt3inqui.ho5 tr.. <br />Wn: l 7n�e� <br />'Gmc ( 53 i� <br />R<r<i�cd by: <br />oxt G i <br />_ <br />Tir•.e� 7 <br />Rrlinqui=dal tn•:° <br />,.� Un:t Lm ?,;✓w} <br />R:.ernd by — <br />OiF[C6 & t anO1L4YOR4 - <br />256D Slae—h Rmd <br />S•.o:ktto, CA ORIS <br />7r1-4204)941 Mat <br />FAA: i2R7! 9421=?i <br />19 <br />ORIGINAL <br />Rush Analysis (stn charge will apply): <br />❑ 5 Day ❑ 4 Day ❑ 3 Day <br />❑ 2 Day ❑ 24 hour <br />Rush, pre•approvat by tab: mot <br />Electronic Data Transfer: yes no <br />Ii yts,To: Stage_ Cli—wit otthher 2 <br />Lab number <br />I <br />Dale Tim: <br />D— T c. <br />Dar Tma______•____,_ <br />Nit Tine �_• <br />mer <br />\i:a!ia_61aarnia <br />Td: (359) 7319473 <br />Mobile-. t559173743y9 <br />Fe \ 159034-905 <br />