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�+ ENVIRONMENTAL CHAIN OF CUSTODY ,� \ fid' <br /> AND ANALYSIS REQUEST DOCUMENT ORIQINAL <br /> Rush Analysis: 5 Days_2 Days_24 hm._ <br /> C <br /> lient: Sampler(s): LfIFFEL'r <br /> Customer Number. QaQC R"vV port �1 eyes no - F If <br /> Address: Electronic Data Transfer: yes no <br /> Comp Sampler Set up Date: Time: If yes,To:State_ Client _Other <br /> l 3 5 5 3 a <br /> Time: Mileage: Lab number. <br /> `,,� — —_ — Lab Loc: SP ❑ STK,(J VI ❑ ❑ <br /> : T7��on:afion(if different from above)G L N I M jf FAffAl � � � Y A ieI <br /> )/ n eoeATMAJ a g <br /> Address:Dnp nY,X a�A/s�s3 < z3 <br /> .,nb1.LCLt�LBy nR 'ln�—�'7`!�. s 3..5 m O G O v Q <br /> L° y z C p l <br /> Phone: p " � v e `✓ c I r V `�> <br /> FAX: <br /> Contact person: .g a pl o Q Uy^. at� Z fW v u U <br /> C e y Y <br /> Purchase order/contt/FGL quote number. (o O o 9 E z p <br /> rac <br /> e v <br /> Pre Log Required:,yes Z <br /> no '� § § rn T O m _ x y °e e <br /> 00 <br /> c <br /> FNumber <br /> Location/Description Date Time �' u F 'ry; z <br /> Sampled Sampled X y o tA W m 6 + CIF U <br /> R C <br /> 3 - e- <br /> R <br /> LI <br /> 5 - WALL r'lO <br /> �- Q <br /> Relinquished by aM subjw b the km ab cmditims m the temse of this dmumea: <br /> Due '9mye RelinquishW by: Due Time <br /> Rmeived by JR Date���j`' 1 , 1� /t67 R.ivedby: Due T.. <br /> RdinqunWby: D.¢ Timeaeu�UiSW by: —G1� Date 1. <br /> Rmeived by: Dae Time :e.wv by: Date �/ / Time 4•¢h <br /> CORPORATE OFFICE h LABORATORY OFFICE k LABORATORY HELD OMCE <br /> P.O.Boa 24/951 Corymuim Strtet 2500 Stsa.h ROW Mwm Califon.. <br /> SmtA Pula.CA 93=7-0 2 Stmbon,CA95213 bf1bil095 )737-1 <br /> TCL(505)659-0910 Tel:1209)9Q-0151 Mobilr.12891T5435 <br /> FAX:(905)5234172 FAX:12m19e24O3 FA%1289)W4NJ5 <br />