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A8olumbio <br /> Analytical CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORMServicSRS �i0` oo�q <br /> S 3902 E University Dr,Suite 4•Phoenix AZ 85034. 602 437 2001•800 695 7222 xO9•FAX 602 437 5308 PAGE <br /> i www casla0 com <br /> f ? I 1 OF CAS Contact <br /> Pr Name Pr ecl Nurnrr6er ` �j i <br /> 6 —.'yC'—' C)6[2 ANALYSIS REQUESTED(include Method Number and Container Preservative) <br /> Protect Mena ` 1'j Report CC PRESERVATIVE <br /> Go w rePreservative Key <br /> tlss`C + t — �� rn i /�� 0 NONE <br /> CV m 4 `V I HCL <br /> ? a o V 2 HNO <br /> 3 H2Sd <br /> 4 <br /> 4 NaOH <br /> r Crory q7 `q fi4 5 Zn Acetate <br /> O m o 6 McOH <br /> L�// ��r77+ 1 r! I� 7 NaHSO <br /> '�C l ` [ ` CID �� QrY p C� I��U QOC / 4 <br /> Zit l ma pqj o Q� w� B Other ACID <br /> lureDAVrsP Name M gyp` �� r •A U a y <br /> P Z �r0� �oC? OU Q� rt0 ��0 ALTERNREMARKCRIPTION <br /> SAIMPLIWb <br /> CLIENT SAMPLE ID LAB ID DATE TIME MATRIX <br /> �'-- o 5 001 dlokt It 916 V-' <br /> C0z r6 0 2S <br /> Ott o63 <br /> f1twol, LIQ 4� <br /> r a nCpf <br /> SPECIAL INSTRUCTIONSSICOJMMENTS _ TURNAROUND REQUIREMENTS REPORT REQUIREMENTS INVOICE INFORMATION <br /> RUSH tSUALHARGES APPLY) _I Rosults Only <br /> iSTANDARD _II Rewits*QC Summaries POI# <br /> JZ—f)� F/J�C` V-(,C(CG REQUESTED FAX DATE (LCS DUP MSIMSD as required} <br /> !!!l <br /> i �fn�•�� 4 � III Rauft+OC and Cabbratwa BILLTO' <br /> 1! Summaries <br /> REQUESTED REPORT DATE IV Data Vehdaoon Repot with Raw Data <br /> See OAPP ❑ —V Speicalaed Farms I Casten Report <br /> SAMPLE RECEIPT CONDITIONICOOLER TEMP CUSTODY SEALS Y N Edata Yes No <br /> R INQUISH D BY RECEIVE <br /> BY RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY <br /> i <br /> Sr�a t Sigrature Sgnasua Sgnalure Signature Signature <br /> Pn <br /> Printed Name J Pnnted Name PnMed Name Pnnted Name Parted Name <br /> Rm Firm n FLrm FirmRmk <br /> -��-o V 30 <br /> Da L)aternme DateMme DatetThm Dalelrame <br /> Drstnbutron Whi m to Ongrkdor Yellow Lab Copy Pink Retained by Client SCOC 0101 08 t) <br /> .� � � �r �r ilttttrs ■� �� � f� � k» 1� ! � � � � � <br />