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-f= CHAIN OFCUSTODY OnIGINAL <br /> El`s V I RO n M ENTAL AND ANALYSIS REQUEST DOCUMENT <br /> r� . sol I kk)�epi R �— ( Rush Analysis: Yes_5 Days _ 2 Days_ 24 hrs._ <br /> Client: Sampler(s):1` Z'6- `b fdCNL_ Subject to surcharge <br /> Customer Number: QA/QC report required: yes no <br /> Address: <br /> Comp Sampler Set up Date: Time: State Form required: yes no <br /> Phone: C�' Q t0(l Lab number: <br /> Time: Mileage: <br /> FAX: <br /> j,,LL[[� Lab Loc: SP STK ❑ VI ❑ <br /> Project name: –7 T 1 w t�5(ja1 W jt� <br /> Contact person:C=lifi f 4 f l a ?i 1rt/r <br /> �ifling Information(if different from above) z U u <br /> 2 x a <br /> Name: 0 V <br /> Address: 3 3 a x t <br /> C7ellO Q <br /> Phone: ii a b <br /> e .o F= <br /> U a <br /> no rn d N Q <br /> FAX: titu <br /> ° <br /> + z F _V Y <br /> Contact person: E C7 a° F o ° x O 4n�� F' Z <br /> Purchase order/contract number: U °' ° O E u] D OC <br /> z_ `� z z a M <br /> • ° 3 3 A rn y �� a eb `° <br /> U g g 1 T 1 U o <br /> Cn UEn <br /> Sample Location/Description Date Time r ' $ p" 3 3 x z r (j <br /> Number Sampled �Sampled F� z P ?3 A d <br /> Re'nq 'shed b nd object a terms a onditionx on the reverse of this document: <br /> Date it Time ,0 0 Relinquished by: DateTime <br /> �^ )—• T• Time <!_3 Received by: Date Time <br /> - r Received by. Date/� _ 1r <br /> to <br /> Relinquished by: ,. Date Time Relinquished by: Date ime <br /> Received by: / Date Time Received by: Date Time <br /> OFFICE h LABORATORY FIELD OFFICE <br /> CORPORATE OFFICE do LABORATORY 2500 Stagecoach Road Visalia,California <br /> P.O.Box 272/853 Corporation Street Stockton.CA 95215 Tel!(209)734.9473 <br /> Santa Paula,CA 93061-0272 Tel:(2(19)942-0181 Mobile:(209)737-2399 <br /> Tel:(805)6590910 FAX(209)734-8435 <br /> FAX:(805)525-4172 FAX:(209)942-0423 <br />