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} ENVIRONMENTAL AND OF CUSTODY ORIGINAL <br /> _� <br /> A AND ANALYSIS REQUEST DOCUMENT <br /> SAMPLING SECTION 11 REPORT INFORMATION <br /> 1�n,, ` ���_ Rush Analysis(surcharge will apply): <br /> Client: �sl,� /��l Sampler(s) <br /> ❑ 5 Day ❑ 4 Day ❑ 3 Day <br /> ❑New Customer _ C Custo( Number: <br /> Address: ( "� (( ❑ 2 Day ❑ 24 hour <br /> N _ Z G, Comp Sampler Set up Date: Time: Rush pre-approval by lab: <br /> �Q inital <br /> Phone: '- Z> 7 J�-1�-! Electronic Data Transfer: yes no <br /> Time: Mileage: <br /> FAX: If yes,To:State lent O r <br /> Project name: Shipping Charge: Pickup Charge: Lab number <br /> Contact person: <br /> Billing Information(if different from above) <br /> Name: _ „ o <br /> Address: _ <br /> C7 ¢ - O 3 F a L <br /> 0 <br /> z l <br /> Phone: C7 > `o <br /> C) <br /> = o <br /> 0 y <br /> FAX: t° ¢ N Q <br /> W <br /> Contact person: a a o F o N z COD <br /> W <br /> Purchase order/contract/FGL quote number: o h v . oo <br /> Fre : Monthly ❑ Weekly ❑ Quarterly ❑ U c v z° v d F_ E O <br /> uenC MO <br /> Pre Log Required: yes 9 Y Other❑ c =° >, O x ` a <br /> o <br /> E U c z <br /> v <br /> 1 ro w c d 'o <br /> Sample Location/Description Date Time c $ n 3 3 3 to <br /> Number Sampled Sampled E-' z t-'' n `3 t?3 �s <br /> © ` % 2 v <br /> 2 l <br /> 2 � <br /> C <br /> Q <br /> F� <br /> RENIARKS SECTION V 11111's Eel <br /> Relinq fished b V, jft the terms and conditions on the reverse of thi dtxu nc <br /> Date Time ReA.hed <br /> Date Timc <br /> Received oy: Date Time ReDat Time <br /> Relinquished by: Date Time Ret Time <br /> Received by: Date Time Rc D 1 [PATire <br /> CORPORATE OFFICE&LABORATORY OFFICE&LABORATORY F1141'D OFFICE <br /> P.O.Boz 272/853 Corporation Street 2500 Stagecoach Road Visalia.California <br /> Santa Paula,CA 93061-0272 Stockton.CA 95215 Tel:(559)734-9473 <br /> Tel:(805)659-0910 Tel:(209)942-0181 Mobile:(559)737-2399 <br /> FAX:(805)525-4172 FAX:(209)942-0423 FAX(559)734-8435 <br />