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Client: MUM (12L Civ <br />❑ New Customer Customer Number: <br />Address: <br />Phone• - 1� ) ^ ! Fax: <br />E -Mail: <br />Project name: <br />Contact person: <br />Billing Inforrl boon differ from above) <br />Name: �(/z <br />Address:��i��M��C��� <br />Phone: Fax: <br />E -Mail: <br />Contact person: <br />Purchase order/contract/FGL quote number. <br />Monthlyo We6lyEl Quarterlyt7 <br />Pre Log Required: yes - Frequency: Othera <br />sMAIIANOM1161 HOW <br />Sample Date Time <br />LocationlDescription Samp sampled <br />Number <br />"oraomte Offices 8 Labora <br />353 Corporation Street <br />3ania Paula. CA 91080 PX, <br />'EL: <br />=AX: 18051525-4172 <br />w rb. trans <br />e.l- gohb<d by: <br />Real. ed b): <br />Office 8 Laboratory <br />2500 Stagecoach Re <br />StocTEL: (20 CA 42-016 <br />TEL: (209) 942-0102 <br />FAX! (209) 942.0423 <br />www.fglinc.com CHAIN OF CUSTODY 0MOVIAL <br />g AND ANALYSIS REQUEST DOCUMENT <br />Sampler (s): Rush Analysis (surcharge will apply): <br />05 Day 04 Day 03 Day 02 Day 024 hour <br />Rush pre -approved by lab: <br />Comp Sampler Set up Date: Time: Electronic Data Transfer: ❑yes Ono <br />Time: Mileage: Ifyes,To:State— Clliient Other <br />ct.:...,;..., rr.�...a Pirk,,n rharne' Lab number: r l� l d S tom/` <br />v m <br />3 � crn = <br />A <br />3 _3 0 <br />0 3 i °¢ O L <br />O m M 5 �O <br />q C C> O V O <br />a n C <br />V o. m e vci C ? F x C <br />a c a C v+ .. y a 0 4. <br />M 0 N U a 4 N �' y <br />Q 0 3 m' p V¢ a+' I <br />E l0 F r F W 0 d <br />V 5 �o O w d V 7 w O °' Z O Q� g <br />Z A 1e 4: fn_ <br />rL z <br />E ofo a ,n <br />m > > s F Y <br />a a A a O 4 <br />z <br />I>' Z > a to m m¢ a e <br />a <br />eandlDdm a careit 4erum. <br />nm.: ` a.linguMb.d be: Dalr:�ma <br />_ Oole: ilm<:jet N...],,d b1: <br />Da, e: Tlmc f�N.IingufMrd M: D.I.: T1­ <br />­ <br />1,,4 <br />ice.' <br />1,.4 b): Dale: Tln r: <br />offleo 8 Laboratory. office 8 Laboratory Office 8 Laboratory <br />563 East Linde Avenue 3442 Empresa Drive. Suilo D visa <br />. Goshen avenue <br />is <br />Chico. CA 95926 San Luis Obispo. CA 93401 uaCA 93291 <br />TEL' (530) 343-5818 TEL: (805)783-2946 TEL: (559) 734-9473 <br />FAX: (530)343-3897 FAX! (805) 7 83-2912 FAX, (559) 734-8435 <br />