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SNO <br /> ORDER ID # �-L tom l <br /> IMNING FRES�CA 9372 EET <br /> a L • 0 A 0 >t I E 7 IMC . <br /> (209) 268-7021 FAX:(209) 268-0740 <br />` CHAIN OF CUSTODYIANALYSIS REQUEST <br /> REPORT TO: INVOICE TO: (OTHER THANK CLIENT) COPY REPORT" (Circle One) <br /> ATTENTION z-�-�pATTENTION: State Dept.of Health (DOHS) <br /> NAME: , Y� NAME: L- Fresno Madera Mariposa <br /> ADDRESS;IA—.),Is DeircX11-1 0 ADDRESS: Tulare Kings Merced Kern 1 <br /> Com. S <br /> OTHER: i <br /> PHONE: <br /> FAX: CONTRACT/PO # <br /> COMMENTS tr�z i k.i;^Q BACTERIOLOGICAL SAMPLES ONLY hROJECT INFO: <br /> PUBLIC ROUTINE�SURFACI_WATER=. __" „REPEAT-CONSTRUCTION REPLAC�NIENT � OOTHER OTHER , b <br /> PRIVATE ANALYSIS REQUESTED <br /> TURNAROUND REQUESTED: (cirde one) <br /> I <br /> ROUTINE RUSH (Specify Date): <br /> SAMPLED BY (PRINT NAME): 1G S <br /> SIGNATURE: <br /> TYPE KEY Drisiking Water DW..: rite Water WW Aqueous <br />+ SoiE<flSoi SL:. <br /> scr <br /> Other-0 (Ds �be in Eoritmerots) <br /> 4 ar SAMPLE la SAMPLED [TYPF <br /> DATE TIME <br /> - <br /> � <br /> ve- <br /> V1 V I <br /> 14 1S <br /> St- <br /> CS <br /> : <br /> Rf U(SHEE?BY COMPAlIY DATE <br /> TIME RECEIVED BY . I+?[P <br /> 2 Z ( c - <br />