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rail V1NVI-IM l`11AL ( t,L A.11V ULA C,U31 UVY <br />--- - ;� AND ANALYSIS REQUEST DOCUMENT ORIGINAL <br />Client: 641t t'o r,&A, Wgge V :Rush Analysis: Yes 5 Days h0Days 24 hrs. <br />FSar (s) : ®HIQS Q (tQ M Subjectt % Wim,Customer Number.Address: A/QC report required : yes no <br />Sampler Setup Date: Time: State Form required: yes no <br />Phone 2/(iJ sc_Z �S' 3:0-L Mileage: j `C /Y%J " Lab number: ` l <br />FAX: <br />Project name: ff Lab Loc: SP ❑ STK ❑ VI ❑ ❑ <br />Contact person: FP� N ►5k;.t.(C. H <br />N <br />Billing Information (if different from above) <br />Name: <br />dress: O ° y' <br />A <br />y o 3 a x o <br />Z v <br />Phone: C7 _R ; ®� b IU H O <br />Qr 'Q C y 0 <br />o s <br />FAX: <br />Contact person: c m Q A �U a N Z W <br />U p. �. v x 6 <br />Purchase order/contract number. p <br />aZ ? a ca O C <br />i " ea z Z W <br />x <br />U c a= m J y o aj r/J C qq tc <br />c p y >. t= a W o e IOu <br />C C C rn V 3 a a O ® ,Ui R Ph <br />Sample Location/Description Date Time �' a a. 3 3 3 W ey' C "-� y <br />Vumber Sampled Sampled Z a icc <br />C ti G S cwt e <br />osf j Noy X <br />'I, I <br />It1 R by and subject t the terms atd conditions on rhe reverse of this docu /t: �! <br />t� Die /) % 7'TTiinte %3' `'1— Relinquishedby: Date Time <br />c �Received by: Date et Time � Received by: Date Time <br />Re. wished by: Date Time Relinquished by: Date Time <br />Received by: Date Time Received by: Date .Dme <br />CORPORATE OFFICE ti Street <br />OFFICE ORY OFFICE & LABORATORY FIELD <br />P.O. Box 277!853 Corporatist Street 2500 S ecoach R� Visalia, California <br />Santa Paula, CA 93061-0272 Stockta�TA 95215 Tel: (209) 7349473 <br />Tel: (805) 65"10 10 Tel: (209) 942-0191 Mobile- (209) 737-2399 <br />FAX: (805) 525-4172 FAX: (209) 942-0423 FAX le- (2 9) 737- 5 <br />