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Reporting Information: Address Invoice To: Q Laboratories, Inc. I <br /> Page of <br /> 1. Client: MF_1 (0) 17- 3. <br /> Address: REQUEST FOR ANALYSIS/ <br /> CHAIN OF CUSTODY <br /> Contact: ,S K(f 0 A-TLT C k Lab Job Number: K. 3ostxP a- <br /> AR Contact -no,j � �N,P I5F(_L Lab Destination: <br /> Address Re ort To: Send Invoice To: Date Samples Shipped: <br /> Lab Contact: <br /> 2. 4, Date Verbals Required: <br /> Date Report Required: <br /> Client Contact PH.No.: <br /> Client Contact Fax No.: <br /> ANALYSIS <br /> Send Report T1 2(Circle one) <br /> Client projec1/P.0.e: VER BhC <br /> Sample Team Member('s) 5 V1 P MAT r-K .QJ <br /> Lab Client Sample Air Date/ Sample Pres.TCont <br /> � <br /> NumberIdentification Volume Time Type Uj p o Comments/Inst., <br /> Collected �- v (� Hazards,etc. <br /> C PfV S 1 SIS 14 3 — <br /> NC PA AS Z 5110 9-i <br /> 05 k M C C D 1 5 S — <br /> A NC PA ro <br /> ►� NC PA B- ) )15 <br /> Clo A C P-A ,= 6 x <br /> a-1 A IU= P4 -A I <br /> 1k_ C <br /> (PI OC-P <br /> u Pr <br /> c PI X <br /> ZA - h <br /> P <br /> . �)C P L - IX <br /> Ick k I K C.T <br /> Relinquished by: TIME Received by., �- DATE <br /> 9E <br /> (Signature) 1� C3 OL7; (Signature) <br /> - <br /> Relinquished by: ((� DAT TIME Received by: TE TIME <br /> (Signature) ! 3: (Signatu — '> <br /> Relinquished by: DATE TIME Receiv y. LIZ DAT TIME <br /> (Signature) (Signature) <br /> Method of Shipment I Lab Comments <br /> ' Sample type(Specify): 1)25 mm 0.45 Um MCEF 2)25 mm 0.8 Um MCEF 3)25 mm 0.4 Um polycarb.filter 4)37 mm 0.8 Um 5) PVC filter diam. pore size___-- <br /> 6)Charcoal tube 7)Silica gel tube 8)Waste Water 9)Soil 10)Bulk 11)Other ___ <br /> COPIES WHITE-JOB FILE•YELLOW-PROJECT FILE•PINK-CLIENT <br /> 4nnhfl;m VA 0141(17 • Toll V714) C10 V00 Vqv (71 Al 579-1149 <br />