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ff II � Pro's.:,, ame - <br /> _; T HE I NIN�G i_/�BOlrit:�O icy, II�i.. I t0 <br /> 2527 Fresno Street, Fresno, CA 93721- Address `— <br /> (209) 268-7021 <br /> Chain-of-Custody and Analysis Request Record Mgr. TL#' <br /> Date 2 Copies To: <br /> Page-_?__ of Analysis Requested <br /> Report To: ^� V\ � ab Due�Date °k; <br /> w <br /> Client Name t Bill To: <br /> ` t �= <br /> Address N cFA 00* t�Ry w <br /> Contact Name Expected Turnaround: � Yt <br /> Phone ❑ROUTINE ❑RUSH VERBALS' ❑RUSH REPORT' <br /> f <br /> 'Additional Fees Apply <br /> Contract/PO# <br /> Sampler Name K J Specify Date: / / ( � q �' c _' •`' :f�3 x� <br /> (print) ❑FAX#. p-\ <br /> �ab Client Sample Sample #!Size/TYpe of C.pntain2r ��`r = PieSeraaGtLtt/H>intlfin�} Lt Cs <br /> t9# Sample ID Date/Tim Type f K.;:m y ry+ <br /> 77 <br /> N. <br /> Doh 0 <br /> 6 /,75- <br /> 6q <br /> ,7Y <br /> Iq 77 <br /> c <br /> x <br /> nh f <br /> _ <br /> Water Sample Ke Comments: <br /> Y <br /> Dept. Initials Daita7Ttr»e t orretlna <br /> Each hazardous sample submitted <br /> for anal sis will be charged a hazard- ❑Drinking Water 601'. <br /> Y <br /> ous waste disposal fee. Clients that ❑Waste Water 602 <br /> retrieve hazardous samples within 30 ❑Ground Water(wells) <br /> days of the analytical report date will ❑Surface Water(rivers,lakes) <br /> be refunded any disposal fees. c�y n <br /> ❑Storm Water <br /> VL <br /> 3 <br /> � DBY`L O _ /�3 7 <br /> ISHED BY: <br /> REVIJQUIS (b /JPRINTED NAME: <br /> PRINTEDNAME: COMPANY: <br /> ' COMPANY: <br /> RELINQUISHED BY: DATE/TIME RELINQUISHED BY; <br /> PRINTED NAQE: COMPANY: PRINTED NAME: COMPANY: % <br /> RELINQUISHED BY: DATE/TIME RELINQUISHED BY:: <br /> PRINTED NAME: COMPANY: PRINTED NAME:.-- '' COMPANY: <br />