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ENVIRONMENTAL CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT <br /> CLIENT 1 , r � a <br /> 1 91 <br /> Rush Analysis(surcharge will apply): <br /> Client:� ��'� CT�(J�� Its:�' Sampler(s') <br /> ❑ 5Day ❑ 4Day CJ El New Customer Customer Number: <br /> Address: !J�-'. ) �. . . ❑ 2 Day ❑ 24 hour <br /> W/ t Comp Sampler Setup Date: Time: Rush pre-approval by lab: <br /> (! vital <br /> Phone: e�'� 1 <� ,r�Z1 Time: Mileage: Electronic Data Transfer: yes no <br /> FAX: If yes,To:State_ ' nt er <br /> Project name: F Shipping Charge: Pickup Charge: Lab number <br /> Contact person: V ((� F w'� F22i_ <br /> Billing Information(if different from above) � �Nnme: {�� �/V `BOO AAddress: =Phone: .c ms � yFAX: v E s oContact person: 3,_.^ rn a zo I m oPurchase order/contmatFGL quote number: - [- 5 <br /> Pre Lo R aired: es Fre uenc Mommy O weekly❑ Quarterly ❑ y° n y u '" a Z O f� ;8 W Y 9 Y - a rz 3 3 - tin <br /> c �v tA yu3' _ ✓ z �O st JpleLocation/Description Date Tim �' H;3mbcrSampled Sampla o 3 m <br /> o � 34 2- <br /> W.30 3a <br /> 0 <br /> CUSTODY <br /> 3 <br /> F <br /> F7a <br /> Reast., Mb ad,h n.,he corms and mMiiions on rhe rtverx ofihis daumenr <br /> C' / Date tolz5�i/�a ���' Rel uiaM1ed bb, "Date Time(JG IDate e ,�rr TimeReliiqui,w by Damt Vl •-�--- Ti <br /> 7 Raeived by: Dme Time Receive Ti <br /> CORPOMM OFNB R LABORATORY OFFICE&LABORATORY n DO <br /> LE <br /> P.O.Box 27Ml..CA 361-02lon street 3300Sn.CA 95 Road YisJia,hlifomia <br /> $Inco05)659A 95061-mR Tel:( <br /> aCA95L5 Tef(539)]54-9lO /�Q <br /> FAX:fl 1659-0910 TCC:(20s,9421 Mobilo(339)]5]&399 J` <br /> FAX;(805)SIIdI]3 FAX:i309)99]-0435 FAX(539)]39-8953 <br />