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r <br /> ENVIRONMENTAL CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT COPY 2 <br /> r 1 �� Rush Analysis(subject to surcharge) <br /> Client c is c• Sampler(s) _ `Q.�� �/ i?y��►� �-y <br /> 4 New Customer Customer Number ❑ 5 Day Ll 4 Day ❑ 3 Day <br /> Address �; - -,C;�' , ;, ❑ 2 Day ❑ 24 hour <br /> Comp Sampler Set up Date Time Electronic Data Transfer yes no <br /> Phone <br /> FAX Time Mileage If yes,To State_ Client Other <br /> Project name U t a U Lab number <br /> Contact person � -a c c. �! „ <br /> Billing Information(if different from above) 7 <br /> Name U <br /> � u <br /> Address u <br /> c� 3 0 u z n Q <br /> Phone C7 S Y , <br /> la v v o O <br /> FAX Ug <br /> Contact person v w c x c <br /> �'c 0 + <br /> Purchase order/contract/FGL quote number � � � � " " u � --• x `° <br /> U e <br /> Pre Log Required yes no on C7 Z Z <br /> N v Vj � <br /> V] C x mu P [� �'+ � liT 0 G <br /> � 3 <br /> G <br /> Sample <br /> Location/Description Date Tithe u u <br /> Number Avg. 3nV y `° <br /> Sampled Sampled F- X F• 4 m <br /> � <br /> �;U� 1 u c, �. 4�'� r�tau r+1 F � l ( v- x <br /> 'C'x U y w 1[, r{1 t4, aj 1, ,~ 4� <br /> X <br /> C <br /> (� iii X p <br /> r <br /> 3 <br /> Meg CUSTODY <br /> Rebnquts�cd by and sub�cc,Ip the t d conditions on the reverse of this ci�unrnl r1 <br /> Date ' I Time t Relinquished by Date Time <br /> Rye ed by ]�1'v't"S� 4 1 1 t 4 t! Time [{uervcd by <br /> ate t^ 'rt f —1 <br /> ,.,_. ` Date Time <br /> Relinquished by Doc Time Relinquished by Date Time <br /> Received by Date Teme Received by Dau; Time <br /> CORPORA E LABORATORY OFFICE d ATORY <br /> AO Hoa 27 tion Saat OFFICE <br /> FIELD OFFICE <br /> Santa Paule CA -0272 Stockton C Visalia Cahloma <br /> Tel (805)659 0910 Tel (2D9)942 IBI Tel <br /> (2012094 3472399 <br />