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ENVIRONMENTAL www.fglinc.com CHAIN OF CUSTODY <br /> www.fglinc.com ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS SECHOOWNIATION <br /> G A-/Ij '-I 4_1Z . l U n Rush Analysis(surcharge will apply): <br /> Client: L(,�' Sampler(s): <br /> )few Customer Customer mber. 1'7-;3'1'7 I/ ❑ 5 Day ❑ 4 Day ❑ 3 Day <br /> Addresst N. Erne, �• fl ❑ 2 Day ❑ 24 hour <br /> Ls-nde4i e9 A Comp Sampler Set up Date: Time: Rush pre-approval by lab: ---- <br /> Phone: LO9- c18�2-l� FAX: Time: Mileage: Electronic Data Transfer yes no <br /> xE-Mail Q yes,To:StateClientOther o <br /> Shipping Charge: Pickup Charge: Lab number: (_ 3 21`18 <br /> Project name: �) <br /> Contact person .] <br /> \Billing Information(if different from above) Flo-1. 3 <br /> 9 <br /> Yame:Address: =Q3vAeo 3o <br /> Phone: PAX: 'ma 3 ° o2E-Mail F n o C=Contact person: 3 m+� zPurchase order/contract/FGL quote number: OMonthly ❑ Weekly ❑ Quarterly ❑ n uPre I,og Required: yes Frequency: Other0 3 3 n �, p Zz m 2 uSAMPLE 1 eekr�3 ' A0 tiample Location/Description Date Time ' 3�3 <br /> Number Sampled Sampled [= Z F' a v,c7 3 in m n. v ¢, <br /> D <br /> r • CUSTODf <br /> Ru by andeb)ugwtheemrmda�mlilnmm we reveexe of�hix 9umcnc <br /> Dam JJ3 7 Time Rchrquishedby. Dpi 1 Time <br /> Re Dmr,J Time Raeivel by Wm Time <br /> RdinyuishN by Dm �� • r' c� Re1m,mxhed by, Daie Time <br /> Received by: W Time 17Remrved bg Dnm Time <br /> CORPORATE OFFICE&LABORATORY OFFICE&LABORATORY OFFICE&LABORATORY FIELD OFFICE <br /> E53 C i ora4m seal 15(10 sug e,weh Rwd 553 E bmir Avenue Vi W„California <br /> S m Paula,CA B Simko,CA 95215 Chive.CA 99I]b Tel:(559)T344071 <br /> Tel:(W5)3so-?0100 Tel (2(H)942-nlfL Tel:(530)343-9818 M Nte:(559)T3T-2399 <br /> FAX!(805)5J 113 FAX:(209)WMWD FAX:(5301343 851 FAX(559)D16435 <br />