Laserfiche WebLink
CHAIN OF CUSTODY <br /> VIKONMENTAL AND ANALYSIS REQUEST DOCUMENT OPY 2 <br /> CLIENT DETAILS SECTION I REPORT LNFORTNIATION <br /> Rush Analysis 5 Days=2 Days 24 hrs <br /> Client o/ Sampler(s) V° r Subject to surcharge <br /> Customer Number QA/QC report required yes no <br /> Address Q32- Afe r 11 c,, Electronic Data Transfer yes no <br /> w 7 Comp Sampler Setup Date 4 i4 M Time If yes,To State Client _ Other <br /> Phone 4 77 `-' 1 <br /> Time Mileage Lab number <br /> FAX Lab Loc SP ❑ STK ❑ VI ❑ ❑ <br /> Project name as4l p 'W4 <br /> rS <br /> Contact person s 1PU !w L U U r g <br /> Billing information(if different from above) x - <br /> z <br /> Name rn a <br /> Address d 0 3 oma. O a <br /> z <br /> c� o <br /> n O <br /> V > a ca o0 b O �, <br /> Phone a <br /> a <br /> FAX dvYa 0. U h Q •�—• IA ' �Q QCd <br /> q <br /> N <br /> Contact person c F o v (ie p, + <br /> Purchase order/contract/FU quote numberto u v c 4 E O M G Z <br /> ar O o <br /> Pre Log Required. Y� no 3 3 1641 <br /> Z <br /> S,kNlpl,E INFORMATION SECTION IV I %; <br /> Sample - LocatranlDescnpuon Date Time °' a y a rn GI C� <br /> Number Sampled Sampled E~ Z .. <br /> 2 M w -S - 21 10zo c n <br /> A4 IV A530 <br /> 4 AlfW -S /0,40t <br /> err cv- '; 3�' 105,0 <br /> MW -5 ' <br /> � 7 MW_ G _ tJ ►� <br /> SECTION V1 <br /> �f ROM CUSTODY <br /> tteltnq died wb the tens c bans on the reverse of this doommcm�./ (,re <br /> Dad IiJ—1 7'1= +' Rdingwshedby Dste Tien <br /> (LOT.. R Received by tkne Time ~� <br /> i <br /> t� <br /> r Rtleepur bY' Date T. \ Rehagmshedbr Date \ Time <br /> ) <br /> Received byA� Due Time Reserved by D.. �-TilC <br /> c� <br /> OFFICE dt LABORATORY FIELD OFFICE <br /> CORPORATE OFFICE LABORATORY250DStageevachRoad YiWia,CalAwnea <br /> PO Box 2721853 Corporanoa Semi Stockton CA 95215 M (209)034 73 <br /> Sam Paula,CA 93061-0272 Tel (209)942 0181 FAX(209)71d 9415 <br /> {209!793 7 2599 <br /> Tel (805)659 0910 FAX (2(19)941(U21 FAX{ <br /> FAX r9nS1 S25 AM <br />