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ENVIRONMENTAL CHAIN OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT COPY 2 <br /> Iwo 011203 IN N[elk, <br /> �, k ( r • Rush Analysis: 5 Days 2 Days 24 hrs. <br /> IC[ien�� tel a t- t-'\ J Sampler(s): _ U , L I\ 1 Subject to surcharge <br /> CN\ � (� Custome �li[mt� 1 �t '•�1 QA/QC report required: yes no <br /> Address: ' <br /> Electronic Data Transfer: yes no <br /> Comp Sampler Set up Date: Time: <br /> :I L _ If yes,To:State_ Client Other <br /> Phone: I , <br /> Time: Mileage: Lab number: <br /> FAX: <br /> Lab Loc: SP Lk STK Ll vi Ll ❑ <br /> Project name: <br /> Contact person: -S <br /> I <br /> Billing Information(if different from above) <br /> o <br /> Name: o x <br /> t u 4 <br /> Address: 3 x Ca s f 'v Q <br /> O o a U p % T <br /> z Q IPhone: <br /> b o :° <br /> FAX: U F o rn t° " C/) — —c rig O <br /> Contact person: ° 3 m 3 O a N Z W v U <br /> Purchase order/contract/FGL quote number: o v v x Q o I <br /> Pre Log Required: yes no U ro Z 3 7� ' a z z 01c ^ <br /> °0 n O A7 <br /> E U � z c 3 �.I ti v " ai c QO.p ro <br /> o S g h In rW _ o a ri <br /> ti V 3 o a j Q > <br /> o o o a x °� N a Z. q o <br /> Sample Location/Description Date Time a E <br /> Number Shmpled Sampled F' z t a c?3 ? p `— ri Fv U <br /> n <br /> REMARKS SI-Cl ION V CUSTOD1, Sl:CTION V1 <br /> _ Relin txhed by and subject;lo a terms a �nditions on the reverse of this me <br /> T <br /> l C. <br /> �- t v �•� J � � c ///� Relinquished by: Date Time <br /> Received by: _ / Date I'. !lime --Y--�t \- � J Received by: Dale Time <br /> Relinquished by: Date Time Relinquished by: Date Time <br /> Received by: Date Time Received by: Date Time <br /> CORPORATE OFFICE&LABORATORY OFFICE&LABORATORY FIELD OFFICE <br /> P.O.Box 272853 Corporation Street 2500 Stagecoach Road Visalia,California <br /> Santa Paula,CA 93061-0272 Stockton,CA 95215 Tel:(209)734-9473 <br /> Tel:(805)659-0910 Tel:(209)942-0181 Mobile:(209)737-2399 <br /> FAX:1805)525-4172 FAX:(209)942-0423 FAX(209)734-8435 <br />