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ENVIROIOWNTAL www.fglinc.com CHAIN OF CUSTODY ORIGINAL <br /> {, ANDANALYSIS REQUEST DOCUMENT <br /> Nam up REPORTINFORNIATION SECTION I]] <br /> Client: �C �/.+y(1 ��'�� �j Sampler(s): U A6,U-' Rush Analysis(surcharge will apply): <br /> O New Customer Customer Number: — S73 ❑ 5 Day ❑ 4 Day ❑ 3 Day <br /> Address: el 6 VAA114 CJEST; Gt m /goo ❑ 2 Day ❑ 24 hour <br /> Comp Sampler Set up Date: Time: Rush pre-approval by lab: <br /> Celt —T <br /> Phone. , e(e�— �3� GsLt� 1{'13-- j <br /> Mileage; Electronic Data Transfer: yes no <br /> Time: <br /> E-Mail ''�/ 1ROPM' �- ( ayA If yes,To:State—Client_+Other <br /> A <br /> Project name: RE -t �'1'p('�"Cp� Shipping Charge: Pickup Charge: Lab number SJ� I S3 q /V <br /> Contact person: JUQ& <br /> Billing Information(if different from above) q 3 <br /> Name: I Q $ h <br /> e <br /> Address: e $ 2 L' <br /> E v o F <br /> QQ n <br /> Phone: FAX: o v 4 C ,L U <br /> E-Mail <br /> LQ h <br /> Conroe � <br /> person: 2C _ `�� y .a ta `z3 F, ( <br /> Purchase order/conuact/FGL quote number $ I�� y ts.' + 6Monthl .7 <br /> _ y❑ weedO Quarterly O m Z a Va s p CW Log Required: yesz zoma O <br /> t <br /> 16 <br /> q <br /> Nample Location/Description Date Time $ E Sr <br /> ber Sampled Sampled rT z' G e ry o— v <br /> gb K W <br /> Z 1 <br /> ►� r <br /> Rel' e0 aW subject s9 de mmeaW mndisi9m 9n ne rtvene of this d99umme <br /> 16 Z <br /> `!W Da.7 Y lL rrt. S Ralbgvlah.d T9a. <br /> a«.i Trt. f(/e^7-/FJ� a...n.a �z <br /> RNiipuishW Dvi.l (( J T.. 1 /�(f 77 <br /> R.linquielxd by. Dat< Tisa <br /> T,. ReaivW by: DsR Timc <br /> coRPo TE OFFICE&LABc, ATDRY OFFICE&LABORATORY <br /> 853 Caponaon asrtes 33a08uanwcM1 ROW PPICE&I BRATORY o03 FmA Drir ATOD omu J ROm TORY <br /> Sv�u Purls,CA 93050 asocYron.CAro <br /> tt3:(805/J92.20W �1rA199 CM1iw.CA 95936 am Wis Obup�3o�ggpQypG�9��310�_1 5'isdis,CA93391 <br /> J� R� 1902-018� �"(SJn13lA ' 5�1 <br /> )903 (t ] <br />