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ZAN ,No '0077'@ C I CUS 0DYILABORATORY ANALYSIS RORT FORM <br /> lervices"` 3334 Victor Court-Santa Clara,CA 95054 S ZO.� ��� P O# <br /> (408[)748 9700•FAX(408)748 9860 SERVICE REQUEST NO. PAGE OF <br /> PROJECT= v• '/�+ P� # Z� � ANALYSIS REQUESTED <br /> PRESERVATIVE HCI HCI HCI NP NP NP HCI HNO NP H SO, NaOH <br /> PROJECT M" l` OQSa xi <br /> rA yQ Co - p �O G <br /> COMPANY w � ��'� Cn ACV O <br /> ADDRESS 2'DZ J9• ���� ¢ 0 ��� � CT -�i <br /> rWL <br /> % <br /> r Om4y�a v0 oo'Q��C,� <br /> PHONE7So?07 do– <br /> D O O �A2 f?s .4 -i <br /> �,te, <br /> �oa mu �an`DX 77-$070O <br /> SAMPLERS SIGNATURE <br /> Om !9r<3y O� pp m a�y� ei m`1 �c Q 60O <br /> SAMPLE LAB SAMPLE <br /> ID DATE TIME I D MATRIX Z eco z� Qr4 U� V 1 REMARKS <br /> ��' • C��a bta <br /> It it{ l (fir <br /> MW-Z.C, •orm I� 3a y <br /> ow-I Q - <br /> n,% <br /> w- 6 • f100 12tib <br /> 0200 Zoe <br /> XF <br /> -Gc• "o 7-co • l (� <br /> v2Z�ID y <br /> ►��.6 -oma Ll� �.�a r,.�- 3 <br /> 1a <br /> RELINQUIS D B� EI -D BY RELINQUISHED BY RECEIVED BY <br /> TURNAROUND REQUIREMENTS REPORT REQUIREMENTS <br /> atur St to 5t nature 1 da — I Routine Report <br /> 0 g Signature y _2 day_3 day <br /> 1 l3 ^ II Report(includes MS <br /> int ame Prin d Nam Printed Name Printed Name —5 day _Other MSD,as required,may be <br /> ,S e r�r2 charged as samples) <br /> Firm Fir Firm Firm Standard(1 worlang ys) — III Data Validation Report <br /> Q�� r ,05 r (includes All Raw 6010) <br /> DatefTime _jDa Datei Time Results Due MDLslPQLslTrace A <br /> Date/Time — <br /> i Ii e.,7 T Electronic Data Deliverables <br /> RELINQUISHED BY RECEIVED BY SAMPLE RECEIPT Condition Custody Seals \ <br /> SPECIAL INSTRUCTIONS/COMMENTS AvF• <br /> Signature Si atur <br /> !tri �G Circle which et are to b analyzed, <br /> d/ <br /> Printed Name Printed Name Metals Al Sb Ba Be B Cd Ca Cr Co Cu Fe Mg Mn Mo Ni K Ag Na Sn V Zn <br /> As Pb Se TI Hg <br /> Dat Firm ' <br /> Date/Trme DatelTime <br /> Shipped Via/Tracking# Storage <br /> Will sample results be used in connection with drinking water regulations? ❑ Yes ❑ No it yes,you must so indicate by writing"DW"for each such sample <br />