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,Z ENVIRONMENTAL CHAIN OF CUSTODY <br /> AND ANAL!!11 REQUEST DOCUMENT <br /> -CLIENT DETAILS SECTIONr l r 1 <br /> / <br /> Client: _ Sampler(s) �QRush Analysis: 5Day s 2Days 24hrs. <br /> FF clnl on.ar Number Subject to surcharge <br /> `'LLQ QA QC report required: yes no <br /> Address: - <br /> ElectronicDataTransfer: yes no <br /> � Comp Sampler Setup Dale: Time: <br /> Phone:� ! V' 2'l If yes,To:State_ Client _Other <br /> FAX: -7 I Time: Mileage: Lab number: <br /> Project name: L-�7 �` NLI V r ( v +r- Lab Loc: SP ❑ STK ❑ vi ❑ ❑ <br /> i <br /> Contact person: <br /> Billing Information(if different from above) <br /> - u t <br /> Name: a U I <br /> V ` & � <br /> Address: <br /> o = 0 3 F a c <br /> 0 3 ° 4 0 ° Z <br /> Phone: qq _ u Z C <br /> C7 6 'g m c a d C, y N S <br /> FAX: ` , .€ y 'o o F V N R'> <br /> Contact person: N1�1 �/ {t o < Ap ami <br /> V N Z A ��[ S abi <br /> Purchase order/contmct/FGL quote number: E ,� ¢°. X F o `�' y a' + N �� L) <br /> Pre Log Required: yes no ,2 2 Z v v �- Z Z (yd a <br /> SAMP <br /> c U c 2333 <br /> LE J v <br /> 1 1 y a .o 06 17 m6 <br /> a <br /> Sample Location/Description Date Time o, E e a rn F" J �� <br /> Number Sampled Sampled l; z P. h v 3 y, W m a e `J ,rC� �) <br /> MWZ sF.n nnlr. Z4oi Nuv Dave la3 `1 IL14. , I / M G <br /> Jr <br /> I IWZ N)rvk pv, 1, � 7} 10.25 ✓ Ni <br /> MILX <br /> 14 am rill N <br /> nhRW a d sullen to IAe terms aM eaMitions on the reverse of thias 1 ment' �/13 z� <br /> I Reliwuished by: <br /> r i 1 DemTime <br /> Rmelvedby: _ Date l' i (Time — _ Received by: <br /> Dam TimC <br /> Relinquishedby; Dam Time Relinquished by: <br /> Date Time <br /> Received by: Date Time Received by: <br /> CORPORATE OFFICE&LABORATORY Dam Time <br /> P.O.Box 2921853 Cnp inion Street OFFICE&LABORATORY <br /> Sante Paula,CA 930610292 25W Smgmwch Road FIELD OFFICE <br /> Tel:(805)659-0910 Stockmn,CA 95215 vis.h,Caliromia <br /> FAX:(805)5254172 TO:(209)9420181 Tel:(209)734 9,173 <br /> FAX:(209)9420423 M.W.(209)9398399 <br /> FAX(209)730.8435 <br />