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UPLItUMA MA tR LABS r P.O. Box 4249 f 1438 Carpenter Lane f Modesto CA 95352 f (219) 521-4851 <br /> Dater-�=� -; �1 °' • R D E R F O R u O • K Orderf Y21-1� <br /> Time: a. - ----------- <br /> --`- Sp' <br /> C L I E 9 T I <br /> Contact Or — <br /> Client: `�!� �Q 7 ---j r , C,� — - Phone: ( )CIL � Representative: <br /> -- --- <br /> Address: L Ci n_4 City �7 - ( t '(\ State. � lip. � �L,G <br /> ---- <br /> ---��--- - - - - ----- - 1-------- <br /> IILLIN6 ] <br /> /� JI Purchase Order <br /> Bill To: �LL�IY� � �-------- Phone: ( ) -I 1 Co � S Or Contract No.: <br /> Address: <br /> — �- ------ ------ ----------- --------------------- <br /> .,`�� �� n pin ( L-- c <br /> ti ---- City: State: fip: �� � <br /> Payment: Cash S ; ; Check S_— — ;x, Bill Other: <br /> SAMPLE LOCATION / PROTECT ] <br /> Address: / L� CI City. �7 -- ? ----- -- p: — — -- <br /> 5�—� ---- -- -------- ------ -----�-- State: Ti <br /> Cross eck -- <br /> Street: U.B. Tank Removals: Number Size Mals Type _______ <br /> ------------- <br /> ----- --- --- ------ <br /> Copy To: <br /> ----- _ ---�5-------------- <br /> NOTE: Attach Any Special Instructions Or Diagrams As Necessary. <br /> SC H E I U L I A 6 1 <br /> Sample: ;k` One Time Only ; Weetly :-1 Momthly ; Quarterly Other: -- — Start late: <br /> Results: ; Routine ; I Silver Rush --- � <br /> Sold Rush �taA <br /> r Times 11 Workdays 5 Workdays ___--_ _-----------— 2 Workdays _ _ _ _ 1 _ <br /> Rate: 1 List Price 1 1.5 x List (Needs Lab Director's Approval) 1 2 x List (Needs Lab Director's Approval) <br /> Lab I.D. S Test Code Test Description/Method Comments List Price Discount Costs Incurred <br /> •' f Z S <br /> Digestion, Extraction, Filtration, Or Any Other Special Handling Per Sample S I S <br /> Field Service Charges S 57 So <br /> Total Other Charges f <br /> TOTAL JOB COST <br /> Film! nruPqi.rea a,.. t ,.e Io.,,. nt rat nop9 <br />