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eporting Inorma = M M tM C <br /> e I_ v, f American Environmentalork IT�{ Pr w age T—e <br /> 1 Client _+_ ._� 34.}0 Vitic,t,nt Rodd Pleasant Hill,CA 44523 <br /> —L-7 <br /> Address Phone(510)930-9090 REQUEST FOR ANALYSIS/CHAIN OF CUSTODY <br /> Contact -I �_�. ( i , t <�� FAX(510)930-0256 , Lab Job Number <br /> Alt Contact <br /> Lab Destination <br /> Date Samples Shipped I I + 1 `�-7 <br /> Address Report To Send Invoice To Lab Contact - ^ I� • <br /> 2 3 Date Results Required 1-2A 7-- <br /> Dale Report Required <br /> – --- — <br /> Client Phone No S��. `�-7 ? __ <br /> Client FAX No <br /> Bend Rep rt To 1 or 2 (Circle one) ANALYSIS <br /> Clrent P� No __ _} Client Protect I D No t f <br /> Sample Team Member(s) If <br /> r <br /> 1 J„-d "` Date/ NO Type , <br /> Lab Client Sample Air, Time Sample Pros of of <br /> Number Identification Volume Collected Type Cont Cont ` �" Comments/Hazards <br /> iP l i1 t c I <br /> T f I l `fa <br /> 0YF C AA url - -7 }. <br /> 1 r L <br /> JA-G Mo <br /> F_ l� `Za y ( 5 <br /> l l ) tI LL <br /> IS, C 11) Ci 1 \ ' ti <br /> Relinquished by DATE TIME Received by i ,l DTE <br /> TIME <br /> (Signature) �� _ ( /, i +f% + !(r . ' (Signature) (` , f, , J h <br /> Relinquishta by ( 17 / / DATEf Ty? �y Received by - DATE TIME <br /> (Signature) - c` / + % / �3tJ (Signature} ( I t i k t ` i_} <br /> Relinquished by DATE TIME Received by ' ) DATE TIME <br /> (Signature) (Signature) <br /> Method of Shipment Lab Comments <br /> 'Sample type(Specify) 1)37mm 0 8 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)Sod 9)Bulk Sample <br /> 10)Other 11)Other <br /> COPIES WHITE JOB FII E YFtI OW PRO IFC T FII F PINK 0 IFhrr <br />