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ENVIRONMENTAL CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT ORIGINAL <br /> CLIENT i <br /> DETAILS <br /> Rush Analysis: 5 Days 2 Days 24 hrs. <br /> Client: Sampler(s): Subject to surcharge <br /> QA/QC report required: yes no <br /> Addr s: J�— (o <br /> Electronic Data Transfer: yes no <br /> O Comp Sampler Set up Date: Time: <br /> If yes,To:State_ Client Other <br /> Phone: O 91 <br /> FAX: Time: Mileage: Lab number: q ),z 2 L-1 <br /> Lab Loc: SP ❑ STK LlVI ❑ ❑ <br /> Project name: <br /> Contact person: A <br /> Billing Information(if different from above) F <br /> Name: <br /> o x u <br /> Address: <br /> ^ a x u Q <br /> O O 3 O O O <br /> 3 O U z r- O¢ I <br /> Phone: <br /> FAX: U rn oNN <br /> .`�• 0. � � F � O Vy � O � �d y�„C <br /> Contact person: o a 3 U N Z A > U <br /> Purchase order/contract/176L quote number: o v o o <br /> U v C7 p c E W D M Oa` I z <br /> Pre Log Required: yes no on Z y` —' �j z z 0 0 <br /> _ _ <br /> ta. o z o v a C7 10_� In tn <br /> 39111111111v <br /> U n o 3 a° eu 4 <br /> a <br /> oUi Q o' <br /> Sample Location/Description Date Time E <br /> Number amp ed Sampled (�' Z t a 3 �' 3 ro° on ¢ H U <br /> I DO 11111 CUSTODY Sl:(,.[ION VI <br /> .r.7 R li uishe by and sd' to a terms a ondi6ons on the reverse of thi ume a /n / <br /> Date / Time ` Relinquished by. Date Time <br /> Received by: Dale Time Received by: Date i e <br /> Relinquished Date Time Relinquished by: Date Time <br /> Received by: 11r2 )t�(�' Date Time Received by: Date Time <br /> RPORA I E&L O TORY OFFICF,di LABORATORY FIELD OFFICE <br /> P.O.Box 272/853 Corporation S et �� Q ,� 2500 Stagecoach Road Visalia,Califomia <br /> Santa Paula,CA 93061-0272 Stockton,CA 95215 na Tel:(209)734-9473 <br /> Tel:(805)659-0910 C Tel:(209)942 0181 <br /> Mobile:(209)737-2399 <br /> FAX:{805)525-4172 �� . FAX:(209)942-0423 FAX(209)734-8435 - <br />