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J 111111111111111180 f LANMMUIT� ttttttt iiv-t 011.7 2=774 <br /> 1 CONCORD, CA 94520 AND ANALYSIS REQUEST <br /> IFN V I R O N M f N 1 A L (510) 685-7852 ,s;t <br /> rttttttt» LAIORAT IIIf! INC (800) 423-7143 10 <br /> Company Name Phone# bl 10 loww 2 ,'ZS ❑ <br /> FAX# �4D ❑ a ❑ <br /> Company Address Site location ��0 w E' _ <br /> rn ° ❑ v _o❑ ❑ <br /> Pr ct Manager /1 Client Project ID (#) �b I o o N + + ❑CL F °_ <br /> NAME y N cc <br /> cc ❑ 0 ❑ z ❑ - ❑ <br /> f attest that the proper field sa ling Sampler me(Prl t} # a Cl ❑ $ ❑ o ❑ ❑ <br /> procedures were used during the collection t7 ❑ N ° ❑ U C © a 0 <br /> of these samples C3 a IX o a_ N ca <br /> Lv ❑ q ❑ y <br /> Matrix preserved Sampling H a C7 w W a. ❑ ❑ ° $ ❑ <br /> Field GTEML a n = � ° UUU �- U � � <br /> Sample Lab # w I-1 0 � a 0.1 Co o d � <br /> p Q w Cr 7+ O C N N X <br /> ID (Lab use only) ►� d o rL o W w�W w _ n z o S <br /> a a pp a U z V4 w Z (<a a y F ►- } i .a r a 0. d a Qa a as CL a v QL a <br /> r7t a rn a 0 x T a V M 0 +- m m 1 X O � w w w w w w w w w H w U � O <br /> 1=0 <br /> —� <br /> 2 <br /> or <br /> _Z2 <br /> 4 <br /> ti <br /> Z _ <br /> A` 5- <br /> t�A <br /> I TAT Special Handling XCIAL DET TION IM$ SS�///,/ REMARKS <br /> Priority t24 hrl ❑ GTEL Contact �r <br /> Expedited(4e hr) ❑ Quote/Contract p <br /> L <br /> 7 Business Days ❑ Conflrmation N <br /> ECIAL REPORTING RE TS Lab Use Only Lot# Storage Location <br /> Other PO p <br /> Business Saes ❑ <br /> OA 1 OC LEVEL <br /> BLUE❑ CLP❑ OTHER FAX❑ Work Order# <br /> Relinquished by Sam ler Date Time Received by <br /> CUSTODY Relinquished by Date Time Received by <br /> RECORD Relinqulshed by Date Time Recelvepfif Laboratory <br /> b � 10 J,5D way in # <br /> Rov 719t - -- --- -- - -- <br />