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Reportino Information: Address Invoice To: Q Laboratories, Inc. Page Z- of O'_ <br /> 1. Client: 3. <br /> Address: REQUEST FOR ANALYSIS/ <br /> CHAIN OF CUSTODY <br /> Contact: Lab Job Number: zl�fYO <br /> AIL Contact Lab Destination: <br /> Date Samples Shipped: <br /> Address Report To: Send Invoice To: 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 eport To 1 r 2(Circje ong) <br /> Client project/P.O.1: Ur t' `c! <br /> Sample Team Member('s) 5 L12 YYaItL— <br /> Lab Client Sample Air Date/ Sample Pres. No. Type <br /> Number Identification Volume Time Type of of >� Comments/Inst., <br /> Collected Cont. Cont. v �o Hazards,etc. <br /> JE5-HJ-A IJc C Y I s <br /> cPAc-Y 7r- <br /> 1-1 <br /> A C TDS I <br /> -- <br /> M c 4 S 6 <br /> Relinquishe N DA TIME Received by: DAT�j` TIME <br /> (Signature) C' ��Ac 1_ _� --� <br /> (Signature) � � i. <br /> Relinquished y: D E TJME Received by: S�A SIM <br /> (Signature) y (Signature) 3 -- <br /> Relinquished b TIME Received by: TE TIN} <br /> (Signature) Signature) <br /> Method of hip en 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 tiller 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 /> Alit! IR-vetT a P->>ni Ave Anobpim CA 01907 . Tel (714) 579-1300 May (714) 579-3448 <br />