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EN V I RO 1-1 M 6-1 rAL AND ANALYSIS REQUEST DOCUMENT ORIGINAL <br /> fn-ALr , Rush Analysis(subject to surcharge): <br /> Client: ,.,-nN `� Sampler(s):1 6-1:;L)-y— <br /> L)New Customer Customer Number: ❑ 5 Day ❑ 4 Day ❑ 3 Day <br /> Address: <br /> ❑ 2 Day ❑ 24 hour <br /> Comp Sampler Set up Date: Time: Electronic Data Transfer: yes no <br /> Phone: <br /> � �� � Time: Mileage: If yes,To:State_ Client _Other <br /> FAX: (�-� <br /> Lab number <br /> Project name- <br /> Contact person: �� V� 1 N <br /> Billing Information(if different from above) I <br /> V v <br /> Name: <br /> b V 4 <br /> Address: � _ oz_ <br /> u 0 u <br /> CJ p 3 3 a� p p Q <br /> A o <br /> 4 z v <br /> Phone: 0 o v .5 �� v <br /> o 0 3 <br /> O n F N <br /> FAX: Q cl ~ U <br /> N a V > ° 0 <br /> Contact person: N Z <br /> F o + E r n u U <br /> Purchase order/contract/FGL quote number: o h p v F= [� �Jc, o <br /> V v z v a z o a I\ c cn I z <br /> Pre Log Required: yes no T O _ Z Q o <br /> _ v x_ <br /> z <br /> SAMPLE INF0101ATION SECTION IV p c t o A N N — F LC' Vj <br /> V) <br /> v a v 3 _ au, <br /> o O O ►1 1 r - 4 C r <br /> Sample Location/Description Date Time n <br /> Number Sampled Sampled H Z -' n v 3 `✓ o] m a < ci (=� V 4 <br /> 0 <br /> 1-H i i i i i i <br /> R <br /> F <br /> Relingd ed y and subject to the terms an conditions on the reverse of this document: '' '' ,,// ,,��,,� <br /> - �Tim�( ']� Relinquishedby: Date Time <br /> Recd �?L��FZ Uatc�7 Time _ Received by: Date Time <br /> R/inqshed by: Date e�" 'I Time f Relinquishe by: Date Time <br /> uiReceived by: Uatn a V Time !5� Received by� Date Time <br /> CORPORATE OFFICE&LABORATORY OFFICE&LABORATORY FIELD OFFICE <br /> P.O.Box 272/853 Corporation Street 2500 Stagecoach Road Visalia,California <br /> San u Paula,CA 93061-0272 Stockton,CA 95215 Tel:(209)734-9473 <br /> Tel:(805)659-0910 Tel:(209)942-0181 Mobile:(209)737-2399 <br /> FAX:(805)525-4172 FAX:(209)942-0423 FAX(209)734-8435 <br />