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R >«K >r-A r" r' h.,, C'A,_=N r'- C'C.__ Of r-"l r— r-7, <br /> AND ANALYSIS REQUEST DOCUMENT <br /> ORIGINAL <br /> REPORT INFORMATION <br /> L n�/1��! f�}�`�. � I7�n �r� Rush Analysis: 5 Days 2 Days 24 hr5. <br /> ClienC . _ Sampler(s): « !I_J�--! Subject to surcharge <br /> �} Customer Number: QA/QC report required: yes no <br /> Address: -C.� Q� J �C <br /> Electronic Data Transfer: yes no <br /> t _ ci r5 <br /> Comp Sampler Setup Dale: Time: . <br /> / QQ q C7 ! If yes,To:State_Q Client _Other <br /> Phone:__r Z 6 f) l�7 '1_63r1 U { O I <br /> FAX: (2017) q q Z 'd q.cJ Time: Mileage: Lab number <br /> Project name: fPG <br /> FM — 2 D 5c) Lab Loc: SP ❑ STK� VI IJ ❑ <br /> �/ � / <br /> Contact person:—1 01411 Y�J (' <br /> Billing Information(if different from above) I <br /> Name: $ f <br /> u <br /> Address: u <br /> C7 a O y p <br /> c Q <br /> O 3 °� O <br /> Y 3 QJ <br /> � w3o 4� ziv ! <br /> Phone:' <br /> O <br /> FAX: o Q W t <br /> Contact person:- <br /> Purchase order/contract/FGL quote number. o v a E+ Gy o <br /> u O rri z <br /> Pre Log Required: yes no ;� .� C7 z a v a Z Z d c <br /> 5 <br /> o a <br /> 'a K z 3 3 A C7 to O <br /> SANIME INFORMATION st.:CTION, IV <br /> o o - <br /> .0- <br /> Sample <br /> o . 00 <br /> v a L M �y o .. <br /> Sample Location/Description Date Time a p 3 3 3 rn <br /> Number Sampled Sampled >~ Z <br /> 131 0--1 ' 3-2- lo•ii � 1 x <br /> i -r3 ' b'i3o u <br /> g1 V <br /> s w- r �zi5 Z 014 C,w3 x <br /> Relinquished by and subjt [ the lama and conditions on the reverse or thisdocument: - - - - <br /> Datt� uQ: i <br /> , l^ 1 u Timt Relinquished by: Date • Time <br /> -Rxeit <br /> ate ��1 q: -Tina Receivedby: - - - ate TimeReliny_ Datt. fes- Timt Relinquished by Date Time ' <br /> r <br /> ' Rectived by: Due Time Received bY: Date � 'r nie� <br /> CORPORATE OFFICE&LABORATORY OFFICE&LABORATORY FIELD OFFICE <br /> P.O.Box 2721953 Cmporation Street 2500 Stagecoach Road Visalia,California <br /> Santa Paula,CA 93061-0272 Stockton,CA 95215 Tel:(209)734-9473 <br />! <br /> Tel:(905)659.0910 Tel;(209)942-0191 While:(2091 737-2399 <br /> FAX:(a05)525-4172 . FAX:12M)942-0423 FAX(209)734-11135 <br />