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ENVIRONMENTAL CHAIN OF CUSTODY <br /> ANDANALYSIS REQUEST DOCUMENT ORIGINAL <br /> 1 • • ' 1 ' INFORMATION SECTION <br /> W <br /> Client: �'AMt�. -j- `AM@�f� ' . 1C 1� Sampler(s �� Rush Analysis(subject to surcharge): <br /> ) U5 Day U4 Day U3 Day 02 Day ❑24 hour <br /> U New Customer Customer Number: -3- ) MJ- <br /> Address: <br /> ;29'&AYY1lAf25}A CRF4it Rn- <br /> Electronic Data Transfer: yes no <br /> RR&41VOnC) Comp Sampler Setup Date: Time: If yes,To:State_ Client Other <br /> Phone: (.5)0) 797-4077 <br /> Time: '-"1N Mileage:_ �i �n <br /> PAX: Lab number: `-' 2-Ll`o <br /> Project time: 7l�� <br /> Contact person r,(s'181F-�. SIC) "517'41777.Cs j) 1`f z <br /> t' a <br /> Billing Information(if different from above) <br /> Name: � B n � U <br /> Address: _ pp <br /> > S3 O m O <br /> Phone: <br /> a O D <br /> FAX: U i 4 t <br /> Contact person: o 3 A <br /> a + �: v <br /> Purchase order/contract/FGL quote number: c x �' d Q <br /> w o <br /> Pre Log Required: yes no z O d c Z <br /> a c a <br /> E U .� zSA-NIPLE INFORMATION SECTION IV <br /> $� <br /> Sample Location/Description Date TimE o a 3 3 F x Z QS�a <br /> Number Sampled Sampled 'n'' ,Z� 0.' �'. m w C <br /> laic l 3l �o G if P/c - 4 X k <br /> a <br /> a <br /> F° <br /> • <br /> Relinquished�by�and subj.to the amu aid cindifiom on da reverse of Ibis daumenl: y <br /> Dit.e� I A Tim /e2/ Relinquished by: nes Time <br /> pR�ec ed by: Dap-3dd�\ Time/�/ `o Received by: Dea Tule <br /> fYDDfel��((��1[[��� rrr��'(� nr�' \ /1 r,� Dale �/�a�l/ Timc Mrsitiahed by: Das Time <br /> O �� M�eMWiaM'CIJ BY. (:4EYHOI IND Date Time Received by: Das 'nme <br /> CORPORATE OFFICE&LABOYATORY OFFICE&LABORATORY FIELD OFFICE <br /> P.O.Box 272/853 Colpimtion Sneer 2500 Slageceach Emil Yvlb,Cdifomla <br /> Sena Paul;CA 93061-0272 Slmkma CA 95215 Tel:(209)734-973 <br /> T.1:(805)659-0910- Tel:(209)942-0I81 Mobile:(209)737-2399 <br />