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=$ ENVIRONMENTAL CHAIN OF CUSTODY ORIGINAL <br /> -_ AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS SECTION I SAMPLING SECTION 11 REPORT <br /> a , a , . , <br /> Cllent /J�G( ( �"/-_5 * D�� Sampler(s): Rush Analysis(surcharge will apply): <br /> J New Customer Cusmmer Number <br /> ❑ 5Day ❑ 4Day ❑ 3Day <br /> Address: ��07 r ( S7— S� ❑ 2 Day ❑ 24 hour <br /> Comp Sampler Set up Date: Ti Rush pre-approval by lab: <br /> � / miw <br /> Phone: / S3"SY I \Time: Electronic Data Transfer: yes no <br /> ---lll---���Mileage: <br /> FAX If yes,To:State_ Clien ther <br /> Project name: <br /> Shipping Charge: Pickup Charge: Lab number <br /> {,� <br /> Contact person: /g //J1.6, <br /> x <br /> Billing Information(if different from above) <br /> 9 ' <br /> Name: � o y '$ Uz <br /> S y <br /> Address: <br /> o m53 OU O <br /> Z <br /> Phone: C7 > _o m .c v c y <br /> FAX: U rn <br /> Contact person: .. �' m 3 m 3 U w ax <br /> t5 Z <br /> o Zdao H, a + W <br /> Purchase order/contracVFGL quote number: E 0. na �' R x O r� <br /> O 12 U c m z I"' O m <br /> Monthly O Wxekly ❑ Quarterly ❑ U e p ° aEa r-f d O G <br /> Pre Log Required: yes Frequency. .. Ei Z g g Z z W Z <br /> Other❑ C N T 0 V <br /> .6 c Z 39 D uo s H y +7 <br /> a U �` S '^.. <br /> SAMPLE SECI[ON I\ A o e v t h r F > r� <br /> Sample Location/Description Dale Time S, d ;it: <br /> E v 5 Z r <br /> Number Sampled Sampled F Z F a " 3 N. to m � o. <br /> 3 Q1 ARC <br /> C <br /> a <br /> m <br /> F <br /> Relinquished by anbl 11 1 c tern and Co inions on am mi'me s d«mens: <br /> Oa( Tme Relida"" y: Due Tme <br /> R«eivad by. Dur'3 .31cmc ( R«<iv Da( T. <br /> Rdirpulaby by: Dam lime Rdi I Tm11. <br /> R«eived by Dae Time R«ei Iaby: D( T�h <br /> CORPORATE OFFICE S LABORATORY OFFICE k LABORATORY FIELD OFFICE <br /> P.O.Boa 2221853 Coryoralion Sueu 2500 Smgccwch Roo Yisatia,Glirania <br /> Sarna NutCA 93M 1-0222 S.kmn,CA 95215 Tcl'.(559)214 W73 <br /> Tek(8051659-0910 Tel:(209)912-0181 Mobil,155912322399 <br /> FAX (805)5251122 FAX (2091912-0023 FAX(559)234-8435 <br />