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CHAIN OF CUSTODY <br /> www.fgline.com <br /> • AND ANALYSIS REQUEST DOCUMENT <br /> I <br /> Client:— ton G eGaii Sampler(s): [A,�c lL Rush Analysis(surcharge wi'1 apply): <br /> D New Customer Customer Number: 'I95G5 <br /> Rush <br /> Address: - yyj b .S'. rtede— C�/�(C. q5-;V0& RDay ❑4 Day ❑3 Day❑2 Day ❑24 hour <br /> Rush pre-approved by lab: <br /> I QO/J a— g 3�& Comp Sampler Setup Date: Time: Electronic Data Transfer:Dyes ❑no <br /> Phone: Fax: Time: Mileage: If yes,To:State_Client Other <br /> E-Mail: ZO 3 y 3—t <br /> Project name: 40-3. C� <br /> Shipping Charge: Pickup Charge: Lab number: <br /> Contact person: `m q <br /> A <br /> Billing Information(if different from above) <br /> Name: 3 ¢ 0 3 a M tr1 <br /> Address: A 3 a 0 3 r a = j <br /> N O _ O <br /> .0 — -- <br /> ir- <br /> Phone: Fax " a Y o a <br /> o > c o ^ v < o m �o <br /> E-Mail: o F o �a O N 1 <br /> a vv v v + z <br /> Contact person: o m <br /> r 0 <br /> Purchase order/contract/FGL quote number: m , z v _ v <br /> c v, o y :: p a - . <br /> a <br /> z z SZMonthly❑ Weeklyp Quarteriyp Z <br /> Pre Log Required:yes_ Frequency <br /> OtherO 1J o w ti v �, a i ✓� mI <br /> 1 o ¢ } <br /> Sample Location/Description Date Time E a y 3 3 33 - 6 .6 a =" z <br /> Number Sampled Sampled 7 a> a <br /> U I NUCL, 15101L I741Z-0 1109 1 C1 I -I - I <br /> I Llj- <br /> "/V 30100 Rdm iab d br as aRbJe<t a and eandulnna an tt/p <m<or tbh aa<amrne /y jjj <br /> dL •I •DO Dotc: /ate/finn..\\ Tl- l p Rrlingvlfbed0 Date: Ti— JnL<7 <br /> 'QO Recelvra by: Dnte: / SCJ Ti-�� 11—i"d by: Date: Tim<: /VV� <br /> Lz47 D y <br /> R<iingvfahed by: Dater ✓-� Tlme:�RellvgvlaRed by: Date: Time: <br /> Received by: Datt/d Tlm<:��' v Received by: Date: Tine: <br /> Corporato Offices&Laboratory Office 8 Laboratory Office&LaboratoryOffice&Laboratory Office&Laboratory <br /> 853 Corporation Strout 2500 Stagecoach Road 563 East Lindo Avenue 3442 Empresa Drive,Suite D 9415 W.Goshen Avenue <br /> Santa Paula,CA 93060 Stockton,CA 95215 Chico,CA 95926 San Luis Obispo,CA 93401 Visalia.CA 93291 <br /> TEL:(805)392-2000 TEL:(209)942-0182 TEL:(530)343-5818 TEL:(805)783.2940 TEL:(559)734-9473 <br /> FAX:(805)525-4172 FAX:(209)942-0423 FAX:(530)343-3807 FAX:(805)783-2912 FA :(559)734-8435 <br />