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rtsngaSson� l♦ I111M w �� I� }� <br /> America EIIVIJUliiJ1�J21t1W4523 <br /> tbVOY�C716 <br /> 1 Client = f t PV <br /> 3440 Vin�tnl Road, Pla asanl Hill, Page of <br /> Address 1'ttnne(510) s.i 9( illt)o REQUEST FOR ANALYSIS/CHAIN OF CUSTODY <br /> a 83 <br /> Contact FAX(510)930-0256 �� Lab Job Number <br /> Alt Contact ititr� <br /> r� Lab Destination <br /> t �1S 1 Date Samples Shipped <br /> Address Report To Send Invoice To Lab Contact <br /> Date Results Required <br /> 2 SL— 3 $ Date Report Required <br /> Client Phone No �� <br /> Client FAX No <br /> —17 <br /> + <br /> Send Report To 1 or 2 (Circle one) ANALYSIS <br /> Client P O No Client Project I D No A r a G\i 4 `3 <br /> Sample Team Member(s) q, <br /> � Q$ <br /> LabClient Sample Air Date/ <br /> Sample Pres No Type 4 4 <br /> Number Identification Volume Type' fl of f. 43 <br /> Collected Cont Cont fti Comments/ Hazards <br /> o1+-1 SNE—S 430 Sot <br /> t7Z A - 034S. 5011 — <br /> �3q Gt <br /> t7-A R- 810 w 0 f it - V o <br /> 5[3 ' — GW 10 WO eir <br /> t> A S 3S Sell <br /> Dtc-,A SB - 10 843 Sot 1 <br /> uqt\ S — 5 Sot L Yyx L-0 <br /> 0(4A c S 13 ` Cr W -900 W411Y — _Y_0A <br /> er 5 -1;-w 90Q <br /> (f�A SQ I -5 920 dot - ( v LV <br /> Wi— I 31015-1 )0A 5 - 935 fall v D <br /> lzl4e- 156 1- GW 50 tr — DA <br /> Relinquished by DATE TIME Received by DATE TIME <br /> (Signature) t ti,, 'j -�� �_ ,, (Signature) "r j + <br /> [, f , 1 <br /> Relinquished by 1 , D7E TIME Received by DATE TIME <br /> (Signature) �; '('` a d (Signature) <br /> Relinquished by DATE TIME Received by ( (J DATE TIME <br /> (Signature) (Signature) <br /> Method of Shipment Lab Comments <br /> "Sample type(Specify) 1)37mm 0 8 pm MCEF 2)25mm 0 S pm MCEF 3)25mm 0 4 pm polycarb filter <br /> 4)PVC filter, diam pore size 5)Charcoal tube 6)Silica gel tube 7)Water 8)Soil 9)Bulk Sample <br /> 10)Other 11)Other <br /> COPIES WHITE JOB FILE YELLOW PROJECT FILE PINK CLIENT <br />