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`IVIRONMENTAL • CHAIN OF CUSTODY S <br /> AND ANALYSIS REQUEST DOCUMENT <br /> Client CA t I —i J {y Sampler(s) E�� l`I U e Rush Analysts 5 Days 2 Days 24 hrs <br /> i <br /> stomer Number ! °Z l d , Subject to surcharge <br /> 124 G 3 l� K Z QA/QC report required yes no <br /> Address <br /> Electronic Data Transfer yes no <br /> Comp Sampler Setup Date Time <br /> 3 If yes,To State_ Chen Other <br /> Phone <br /> Time Mileage L <br /> FAX g Lab number 1 loo <br /> Project name r f o 1I Lab Loc 5P ❑ STK ❑ VI ❑ ❑ <br /> Contact person 'Ef V 'Ao b-,A C v <br /> 3 .] <br /> Billing Information(if different from above) F a <br /> Name 7:1 U V <br /> W v a x ro <br /> Address 0: ((r b <br /> ro <br /> C7 p O v a p C) <br /> w A C* o <br /> Phone _ V > `- m m y v z C O <br /> FAX U o > � <br /> d Q7 in � ¢ N NIZ: ro <br /> Contact person f o Q ix a + f h <br /> V� sc <br /> Purchase orderJconlract/FGL quote number o r bb [y o Z <br /> Pre Log Required yes _ no t? z y v z z O o <br /> O <br /> Sample Location/Descriptton Date Time $ E <br /> Number Sampled Sampled z F' ° _°3 M w U <br /> REMARKS sl:CTION, V 001141 HIM <br /> [Rmciwcd. <br /> by sublet a rms and conditions on the reverse of this document <br /> c <br /> C R Date Time s ReUngwshed by Date Time <br /> eived by Date�1 'r�Tune C Received by Date Time <br /> inquished by DatTime Relinquished by Date 15me <br /> by Date Time Received by Date Time <br /> CORPORATE OFFICE&LABORATORY OFFICE&LABORATORY FIELD OFFICE <br /> PO 8nc 272A53 Corporation Street 2500 Slagecoach Road V"alm CaIltUrma <br /> Sano Paula,CA 93Ub I A272 Stockton CA 95215 Tel (209)734 9473 <br /> m enc isn m n <br /> 1 1 — — ". k,; tk t, on057M17 ioo <br />