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Reponmg I,fonnaaon: u• AEN <br /> J <br /> Anric•ul: Entire»tnurrdcrl Ncltrul'k L v Page_ of <br /> 1. Client: <br /> Address: rf' t 344(1 Vincent Road.Pleasant Nill,CA 94523 S lei y <br /> _ r'/urr C Phone(510)930-9090 REQUEST FOR ANALYSIS/CHAIN OF CUSTODY <br /> Contact: <br /> [;AX(510)930-0256 R-5/S-F Lab Job Number: <br /> Lab Destination: <br /> Alt.Contact: <br /> Date Samples Shipped: <br /> Address Report To: Send Invoice To: Lab Contact: <br /> Date Results Required: <br /> 2• Sc'a1F E 11e rso11-fir f c P, 3' Date Report Required: <br /> F W Client Phone No.: <br /> 5-V42 Client FAX No.: Sf O Hn i `- 79 O/ <br /> fJM ' f l <br /> ANALYSIS <br /> Send Report To: 1 or 2 (Circle one) <br /> Client P.O.No.: L' '�'2!!'�C./ Client Project I.D.No.: <br /> Sample Team Member(s) <br /> . Cv q� <br /> Lab Client Sample Air Date/ NoType <br /> Sample Pres. of of <br /> Number Identification Volume Collected Type. Cont. Cont. v v Comments/Hazards <br /> 2A G– 5 /ny ✓ ✓ vv <br /> p — G9 V ✓ --/ ✓ V' ✓ <br /> 05A C11 - P1 PA15.5 v �' v ✓ <br /> Relinquished by: DATE TIME Received by: DATE TIME <br /> (Signature) $ ( (Signature) 10_/ 1 7 <br /> Relinquished by: DA TIME Received by: DATE TIME <br /> (Signature) (Signature) <br /> DATE TIME Received b <br /> Relinquished by: y: DATE TIME <br /> (Signature) (Signature) <br /> Method of Shipment Lab Comments <br /> 'Sample type(Specify): 1)37mm O-.81j MCEF 2)25mm 0.8 pm MCEF 3)25mm 0.4 pm polycarb.filter <br /> 4)PVC filter, diam. _ pore size \ )Charcoal lube 6)Silica gel tube 7)Water 8)Soil 9)Bulk Sample <br /> 10)Other 11)Other <br /> COPIES: WHITE-JOB FII YELLOW-PROJECT FILE PINK-CLIENT <br />