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ENVIRONMENTAL CHAIN 01" CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT COPY 2 <br /> Rush Analysis(subject to surcharge) <br /> Client (a Sampler{s) '�O.+C� CE' <br /> 0 New Customer Customer Number ' � ❑ 5 Day ❑ 4 Day ❑ 3 Day <br /> Address �� 11"` "\c: � , L ❑ 2 Day ❑ 24 hour <br /> f , <br /> Comp Sampler Set up Date Time Electronic Data Transfer yes no <br /> Phone <br /> FAX Time Mileage If yes To Stale_ Client other <br /> Protect name tJ + ,,�V Lab number <br /> Contact person ti -�c C.I ` , 5 c <br /> Billing Information(If different from above) E' <br /> Name <br /> Address a <br /> 3 <br /> p 3 O O O <br /> Phone o <br /> > to a Q <br /> FAXoN �� S <br /> 4v�1 E U k- 1n N u .'�' U <br /> Contact person ° <br /> cK q <br /> a <br /> U z <br /> Purchase orderlcontract/FGL quote number E a. F O a rC x �° <br /> V ani p ro ix rn <br /> 0 O M r <br /> Pre Log Required yes no Z 5 Z 1 <br /> � � _ � � y z Q <br /> a o 3 3 C3 rn <br /> SAMPLE INFORMATION SECTION IV C3 coo <br /> Sample :R! Location/Descraption Date Iim 3 3 u u H d h Ea <br /> Number Sampled Sampled H Z H v 3 U' rA m "? a fa: U q <br /> a a <br /> x <br /> x <br /> Q <br /> r .n <br /> a icx`�� z� IC�c7 f x .] <br /> CUSTODY SI:C,I,I()N V71 , <br /> 11 <br /> Retialluabed by and subrett the[ T11d conditions an the reverse oFlhis document <br /> jj <br /> —�- - } Dole Time ` [r S Relinquished by Date Time <br /> y � t't r!t �� 1 ) h l tc ttf Dae L.,_ 1 `7 t 4 y <br /> Received b �I Time ecnvcd b Date T[mc <br /> Relinquished by Dale Time Relinquished by Dale Time <br /> r77i Rcmwed by Date Time Received by Date Time <br /> CORPORA !CE 4 I,AI{ORATYIRY OFFICE RATORY FIELD OFFICE <br /> PO Roa 27 ration Street 2500 Sia udd Visalu Caldomia <br /> Tcl (NOS) <br /> 1-0272 Sloctlan IS Tel (269)734 9473 <br /> Tel (96516596410 <br /> CbY Lll,"c i,, <br /> Tel 1209)942-01a1 Mobdc (20A7131 2399 <br /> � <br />