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E1`�v �RGr , >L�ILf , iAL ' U'"" tff —FW, "117("Y I. <br /> AND ANALYSIS REQUEST DOCUMENT - <br /> /� ` Rush Analysis(surcharge will apply): <br /> Client: -� .�� '� A SS�Lq � /j Sampler(s): FXbY�-r. C�c—trG <br /> ❑New Customer Customer Number:J_ / �� ❑ 5 Day ❑ 4 Day ❑ 3 Day <br /> Address: Cr1�D 2- 1 V,� S� ks W e=�, ❑ 2 Day ❑ 24 hour <br /> l.y q S Z Comp Sampler Setup Date: Time: Rush pre-approval by lab: <br /> MW <br /> Phone: 3-tv I Electronic Data Transfer: yes no <br /> C. Time: Mileage: <br /> FAX: 3(9 4 -2--�2)� If yes,To:State_ Client <br /> _]Onther <br /> Project name: \K, G7G'�,"(4�— S Shipping Charge: Pickup Charge: Lab number: aS'TK!O�tl7O <br /> Contact person -4!L'n g <br /> 3 <br /> Billing Information(if different from above) � <br /> ° U <br /> Name: �_ & a S x <br /> Address: <br /> Q O <br /> OF= <br /> m �_ °°� m <br /> Phone: 0 Z o ro c /1 <br /> FAX: U ° t 'c y o ["' tom" (yq (Z <br /> � y o f rr o y � o <br /> Contact person: E a � �0 R CL .. �y `+ z <br /> Purchase order/contract/FGL quote number: ° u, —p <br /> v O r O <br /> Z. <br /> m a <br /> Monddy ❑ weekly 0 Quarterly ❑ U c t7 ° E 0. W <br /> Pre Log Required: yes, Frequency: he O W z B i. O ° z <br /> 'o c z 3 3 a« V y z y <br /> A <br /> U i 8 y -7 ei <br /> SAMPLE <br /> INFORMATION <br /> a , N ° <br /> ° x ° M° <br /> Sample Location/Description Date Time �'. 3 b' 5 ,� 2 <br /> Number Sampled Sampled t✓ z <br /> ' ice 4 v-za.k cv�ifi r_ veA(t � `7:36 <br /> 1[7IIZ C, Waa6Qfrt^cQ <br /> /Ct1 r,�c.. /✓cA <br /> c <br /> 0 <br /> a <br /> F <br /> F71CUSTODY <br /> Reli�p.,(jjjj/tlh}'aM subje o N<wrlm ead wndiuom on the rtvuae of Utis docu t <br /> Dale!` I(�On Time 10 V V RenvquiehMb Due Time <br /> R IvW by: Daaj �f O G�1( 0 <br /> + Timc L9 00 RaeivM by: De¢-Time 'e <br /> Relinquished by: DaTime //�L QReliuielei by::!!!y DSR T. <br /> R.Wed by: aDueTime r /0 R.NM by: Dale Tae <br /> CORPORATE OFFICE&LABORATORY OFFICE&LABORATORY FIELD OFFICE <br /> Senln Ple3 25W Sla,.nh Road YW is.CelilmisPO.Boeu27.YCmostreet <br /> Stmkwn,CA 95215 Tel:(559)739-9673 <br /> el:(W5)392-2000 Td:(2M)%2-0181 Mobile:(559)737-2.399 <br /> :(805)5254172 FA3L(209)M2-0423 FAB(559)734-8435 <br />