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*TEL4080 PIKE LANE AND ANALYSIS REQ UES <br /> CONCORD, CA 94520 0at i6b * <br /> It <br /> V IROM YF N IAL 415 685.7852 <br /> 800 A23-7143 OUTSIDE CA 600 544-3422 INSIDE CA <br /> LA{pQAFOIIEf IMG <br /> ' Rhone# t1123, <br /> Company NamP ❑ �N� Ter e, FAX# ❑ I: '� ❑ ❑ <br /> Wm <br /> Company Address <br /> Site location Q , —TI_ - -}"D 0 Cl) _ o <br /> = ❑ r N u a. ❑ ❑ u <br /> Protect Manager Cllant Protect ID (N)��Q (�,2.1 \ co .� Cn Cn N = cc <br /> Ji £ a ❑ ❑ <br /> ice'' V`� NAM a ❑ ❑ ❑ ❑ <br /> I attest that the proper Haid sampling Sampler Name(Print) i M 2 a Q ❑ a ❑ m e a a 5 g ' `- <br /> procedures were used during the collection SSD _ 1 cs p o a N ❑ ❑ u t ❑ a N p a <br /> r Iv ❑ $ p cn �n a N a � ❑ m <br /> of these sem les N W " `—_' "' y m a W cc ❑ LL <br /> Matrix Method Sampling W � ❑ W - a H ❑ a ❑ E <br /> Preserved r ❑ w W =° ., 0 ❑ <br /> GTEL T y <br /> Field - ❑ a $ m g ❑ <br /> o <br /> Sample {.,Lab # C'j 12 <br /> a 0 M <br /> �❑ {Lab US9 OClly� U0 It <br /> W Z <br /> W LW7 0 W O y M_ <br /> � � O = C ui W a SW I— w Z T <br /> R t I 0. 0 r S Y V I F- m m = O H <br /> w w w uai w w IU— w U O v <br /> i <br /> I <br /> d <br /> 1g 2 <br /> Special Handling SPECIAL DETECTION LI S REMARKS <br /> TAT <br /> Priority(24 hr) ❑ GTEL Contact J <br /> Expedited(48 hr) ❑ Quote/Contract N <br /> 7 Business Days ❑ Confirmation# SPECIAL REPORTING A OUIREMENTS Lab Use Only Lot # Storage Location <br /> Other PO# <br /> Business DaVs ❑ <br /> OA I OC LEVEL <br /> BLUE C(_p❑ OTHER FAX❑ Work Order# <br /> Relinquish y 5a pier Time Received by <br /> 2(4- <br /> 31- <br /> Dafe <br /> Rehnquishe by Time Received by <br /> CUSTODY <br /> RECORDRelinquished by Date Time Received by Laboratory <br /> • I qWa III# <br /> '�` Rev 7191 <br /> a <br />