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I Client <br /> -Z aS ��• {ia13440 Vincent Road,Pleasant Hil 94523 <br /> Address REQUEST FOR ANALYSIS/CH&F CUSTODY , <br /> Phone(5 10)930-9090 <br /> Contact J d n ��� FAX(510)930-0256 Lab Job Number r 03 50 <br /> Alt Contact e r 2 RECEIVED APR 0 4 1997 Lab Destination <br /> Dale Samples Shipped <br /> Address Report To Send Invoice To <br /> Lab Contact _ <br /> rr Date Results Required K 7f <br /> 2 �1eGt r 3 Date Report Required LD <br /> 22—'7 v r Ci-k :Ir \u y Client Phone No c <br /> 0C',Y l n 67\ °t LA GV Client FAX No <br /> ANALYSIS <br /> Send Report To 1 or G)n(Circle one) <br /> Client P O No "//k Client Protect I D No w 1Q 4 <br /> Sample Team Member(s) <br /> � �,,�� •�r�t�anS QJ <br /> Lab Client Sample Air Date/ <br /> eSample Pres of No Type <br /> Number kdenttflcabon Volume Collected Time Type Cont Cont day' Comments/Hazards <br /> p! H C t v 0 A k <br /> 6.2 A-c nit w L t u55 <br /> 0 -c /\Aw- -� #z,4s <br /> ray d e Mw' j'Lou I I Yl <br /> -A C n/A w-C, 140 <br /> 0 6 NJ <br /> Relinquished by DATE TIME Received by 1 r DAT //-TIME <br /> / <br /> (Signature) �/ t � >�'- (Signature) j��s�i/rr� /s �� 1`fC s <br /> Relinquished by ,DATE TIME <br /> � Received wed)� DAT� <br /> TIME <br /> (Signature)(Signature) C •j°r <br /> Relinquished by r DA E TIME Receiv y - ATE TIME <br /> (Signature) (Srdna(re) <br /> Method of Shipment Lab Comments <br /> 'Sample type(Specify) 1)37mm 0 8 Nm MCEF 2)25mm 0 8 pm MCEF 3)25mm 0 4 Nin polycarb filter <br /> 4)PVC filter, diam pore size 5)Charcoal tube 6)Silica gel lube 7)Water 8)Soil 9)Bulk Sample <br /> 10)Other 11)other <br /> COPIES WRITE JOB FILE YEI LOW Pn01ECT FILE PINK CLIENT <br />