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ENVIRONMENTAL AND OF CUSTODY COPY 2 <br /> AND ANALYSIS REQUEST DOCUMENT <br /> Client �icy c:�a u .» �, �« C `\E7s�Q_ r 1 �� Rush Analysis(subject to surcharge) <br /> Samplrr(s) �^ ❑ 5 Day ❑ 4 Day ❑ 3 Day <br /> ❑New Customer Customer Number 1 <br /> Address -c p �r�, L ��, ❑ 2 Day ❑ 24 hour --� <br /> '2:i':2 U] Comp Sampler Set up Date Time Electronic Data Transfer yea no <br /> phone �� 1 -��CS r <br /> Time Mileage if yes,To State_ Client Other <br /> FAX <br /> Project name � } o'l_ \?.� �{ Lab number <br /> Contact person _34 4_kJk 1. r <br /> • t= '� <br /> Btlhag lnformauon(if different from above) <br /> U <br /> Name g <br /> Address <br /> [7 O <br /> Photic o m c 'G °t h v to J !J <br /> FAX V <br /> rn � Ca <br /> Contact person o a U + Z .. j <br /> Purchase order/contract/FCL quote number c Cj A <br /> U p Z7 {~ A +f C <br /> CO <br /> Pre Log Required yes no Z 1 N d r z Ae; q <br /> a y u <br /> A <br /> 0 <br /> Sample 4h6a r. tocation/Descnption Date T. �i � � �" �3� to �W W � � � z <br /> Number Sampled Sampled F• (~ �3 04 as ra ti F" U rs <br /> IlG P 3 x <br /> r t 1~7 <br /> Gr <. <br /> O <br /> RelinAur-*by and sub}ecl to le s s�pQcorxLlion$m the rcrcr or this documcnl <br /> r f t1 / ) � <br /> rlfxl +t' "� Pate �� o` Time f Rebnqulshed by Date Time <br /> Reccived by Z- 1 Receival by Due Tame <br /> Rclmquished by Date Time Relinquished by Date Time <br /> Received by Iota-Tim Received by Due Time <br /> CORPORA k LABORATORY OFFICE k RATORY FIELD OFFICE <br /> PO Boa 27 tan Stmt 2500 Stag Visalia Cahfowis - <br /> santa Pwla.CA -0272 Stockton C Tel (209)734 4473 <br /> Tel 405)659-0910 Tel (209)94 91 Mobile (204)737 23 <br /> 0 <br /> ^^ Fav r�rrnoa')nalt FAX(20917346435 <br />