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Reporting Inbr ��N <br /> i <br /> 1 Client Amel lCuj? �1?V11012Y12C'17W eN)w k FM <br /> o, Page of <br /> Address � 3440 Vincent Road Pleasant Hill,CA 94523 <br /> _ f Phone(510)930-9090 REQUEST FOR ANALYSIS 1 CHAIN OF CUSTODY <br /> Contact FAX(510)930-0256 Lab Job Number <br /> Alt Contact Lab Destination <br /> Date Samples Shipped <br /> Address Report To Send Invoke To Lab Contact <br /> 2 (1/ v �' S 3 S" Date Results Required <br /> r <br /> Date Report Required <br /> -L34 115 <br /> Client Phone No <br /> Client FAX No <br /> Send Report To 1 or 2 ircle one) ANALYSIS <br /> Ghent P O No ProI D No --- — ,• .� <br /> Sample Team Member(s) <br /> Lab Client Sample Air Date/ Sample No Type `t, <br /> Number Identification Volume Time p, Pres of of M <br /> Collected Type Cont Cant ` Comments 1 Hazards <br /> � r <br /> I <br /> Relinquished by DATE TIME !Receive1by , <br /> t DATE ,(Signature) TIME <br /> a hi�Relinquished y DA E(Signature) TIME ' TETIME <br /> Relinquished by DATE TIME Received by .y DATE TIME <br /> (Signature) - <br /> Method of Shipment (Signature)Lab Comments <br /> 'Sample type(Specify) 1)37mm 0 B um MCEF 2)25mm 0 8 pm MCEF 3)25mm 0 4 pm polycarb filter <br /> 4)PVC filter, diam pore size 5)Charcoal tube 6)Silica gel tube 7)Water 8)Soil 9)Bulk Sample <br /> f 0)Other 11)Other <br /> COPIES WHITE JOB FILE YELLOW PROJECT FILE PINK CLIENT <br />�r- <br />