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EI`iViR61-lMt1- fAL ' CIA,xIN1%,A' CL"T01, I <br /> AND ANALYSIS REQUEST DOCUMENT ORIGINAL <br /> SAMPLING SI: REPOWFINF014NINIXF10N S11-TION IIII <br /> CTION 11 <br /> f 5 n `�`, Rush Analysis(subject to surcharge): <br /> Client: L 1 1 r..Se)t-� Sampler(s) ��N� <br /> 0 New Customer Customer Number: ❑ 5 Day ❑ 4 Day ❑ 3 Day <br /> Address: ❑ 2 Day ❑ 24 hour I <br /> Comp Sampler Set up Date: Time: Electronic Data Transfer: yes no <br /> Phone: yes,,To:State Client Other <br /> tU l 3 3 G Time: Mileage: Y _ <br /> FAX: � Q <br /> Project name: Lab numher <br /> Contact person: �� uJ-� 1 v <br /> L <br /> Billing Information(if different from above) <br /> A 5 ' <br /> o U y <br /> Name: <br /> x u <br /> Address: <br /> C7 ¢ <br /> �5 <br /> c= 3 O a z v ¢ I <br /> Phone: ? E m $ v u,O <br /> _ U U Y O <br /> FAX: U EFo N o y u N �h v <br /> �' U <br /> Contact person: o ° 3 m 3 Q U x N z <br /> Purchase order/contract/FGL quote number: o r v v F: V o <br /> O <br /> U o v E m " I Z <br /> Pre Log Required: yes no �o �? z vE ' a z O p <br /> rn Gy <br /> c v a 3 3 v a <br /> 6, U z <br /> SAMPLE INFMCNIATION SI:CTION IVN o U° b h v <br /> Sample Location/Description Date Time n g a h o 3 v g z a ; u <br /> Number Sampled Sampled F- Z — Co m a Q U y <br /> n <br /> C <br /> Q <br /> .n <br /> m <br /> H <br /> 11113 fill <br /> I I <br /> lingd ed y and subject to the terms an conditions on the reverse of this document: <br /> -.--._ - Tin, �✓ Relinquished by: Date Time <br /> if��L 4112Date��Time Received by: Date T.me <br /> inquished by:_ Date�") —' TimeRelinquiahe by: Date Time <br /> ceived by: Dale /-�!`De Time 15� Received J Date Time <br /> CORPORATE OFFICE&LABORATORY OFFICE&LABORATORY ! FIELD OFFICE <br /> P.O.Bos 272/853 Corporation Street 2500 Stagecoach Road Visalia,California <br /> Sara 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 />