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Reporting Infor n: 4 <br /> 1. Client: r RL.�A7 3'- r �I11 '!"ICCIIl �IZVII"o121nent(irNetwork ALN r- j Page of <br /> Address: / [` 3440 Vincent Road,Pleasant I-fi11,GA 94523 REQUEST FOR ANALYSIS/CHAIN OF CUSTODY <br /> Q4 VZ Phone(510)930-9090 : " <br /> Contact: FAX(510)930-0256 Lab Job!Number: <br /> All.Contact: Lab Destination: <br /> j Date Samples Shipped: <br /> Address Report To: Send Invoice To: Lab Contact: <br /> 2, a 3 s Dale Results Required: <br /> Date Report Required: <br /> Client Phone No.: <br /> Client FAX No.: <br /> Send Report Too, or 2 (Circle one) ANALYSIS <br /> Client P.O.No.: ' Client Project I.D.No.: J�� <br /> ,mple Team Member(s) <br /> No � . <br /> Lab Client Sample Air Time bate! Sample prey. of Toe <br /> Number Identification Volume Collected Type. Cont. Cont. Comments/Hazards <br /> -4. - 1 ! Tl <br /> vat{ }r x X <br /> (4 <br /> L id�t <br /> Relinquished by: DATE TIME Received by: DATE TIME <br /> (Signature) C�,<.� 7— (Signature) <br /> Relinquished by: DATE TIME + Received by: DAtt TIME <br /> (Signature) f (Signature) <br /> Relinquished by: DATE TIME ± Received by: DATE TIME <br /> (Signature) (Signature) <br /> Method of Shipment I Lab Comments <br /> `Sample type(Specify): 1)37mm 0.8 pm MCEF' 2)25mm 0.8 pin MCEF 3)25mm 0.4 pm polycarb.tiller <br /> 4)PVC filler, diam. pore size 5)Chprcoal lube 6)Silica gel tube 7)Water -8)Soil 9)Bulk Sample <br /> 10)Other ' 11)Other <br /> COPIES: WHITE-JOB FILE i YELLOW-PROJECT FILE PINK-CLIENT <br />