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El`IV I RO1`I ME1`(TAL CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS SECTIONI SAMPIANG SECTION 11 REPORT INFORMATION SECTION III <br /> Client I fl 1g kCLEL6. YV&—"9 ' Sampler(s): Yl'1-T- rn� Rush Analysis(subject to surcharge): <br /> r.C <br /> 7 New Customer Customer Number: 1- 139-719 ❑5 Day ❑4 Day 03 Day ❑2 Day 024 hour <br /> Address: Electronic Data Transfer: yes no <br /> Comp Sampler Set up Date: Time: If yes,To:State_ Client _Other <br /> Phone: 9 <br /> Time: ` J Mileage: <br /> FAX: <br /> Project name: 141&'80 MA'e54 CCK � Lab number <br /> Contact person: <br /> ' ' 3 <br /> Billing Information(if different from above) °� I <br /> U <br /> lame: v a a U A•7 <br /> Address: m x `✓ <br /> OF. <br /> 3 s I C <br /> ' ago <br /> u z C Q <br /> Phone: C7o s = a $ 5 y v !\ u; <br /> FAX: H o` h r0 o ` h Y •� <br /> Contact person: o 3`1 9 V u `V z cy <br /> E p°, B y ti �, °� + e F RU Q Pi <br /> Purchase order/contract/FGL quote number: 0 12 U c m z (A °' o <br /> Pre Log Required: yes no Ue'9 c y W O D <br /> zv & z a e <br /> tZl <br /> e t u.. .9 a] .�. u y T .� t•^ ^ "y FV A F A e d <br /> SAMPLE <br /> 1 1 • w u° m m v 3 <br /> Sample Location/Description Date Time E; <br /> Number Sampled Sampled P z [�" e' °:°3 m m C1. 9 C V I rii l'1-.f: U <br /> L 11'.S6 G D C-/w <br /> �3L w <br /> 143 G 4 IP If C,,VJ <br /> ANALYSES PERFORMEO IN STOCKTM <br /> r Q <br /> .n <br /> F <br /> SECTION11 Did YIN IN CLjS'1'01)y <br /> Reli shed by and subjxt t rhe to d oandiuous an the reverse of 0tts daumene ' <br /> Dale Time Relinquisbedby: 5] ✓D Time! 7 <br /> Received',4& Date 5-,�-� Time�y� Received by: t� Dete _J5 !-0U T-13 <br /> h� <br /> r13Y: GREYHOUND7 <br /> r77tL F V HED BY: Y. STARR Daley 1-00 Time Relinquished by: �m Time, <br /> Re2eyl- Dam Time Received by: Dme time <br /> CORPORATE OFFICE&LABORATORY OFFICE&LABORATORY FIELD OFFICE <br /> PO.Box 2]21853 Car mmion Stscet 2500 Sm..b Roel VaWfit.California <br /> Same Pama,CA 93061-0292 Stedne.,CA 95215 Td(209)934-9413 <br /> Tel.(805109-0910 Td:(209)942-0181 MW,0=717.91W <br />