Laserfiche WebLink
• t www.fOp�linc.com CHAIN OF CUSTODY oRM4 <br /> www.fglinc.com ANALYSIS REQUEST DOCUMENT <br /> CLIENT DETAILS S ECTI 0 N I SAMPLINGREPORT ' <br /> Client: d-< ro'tci Sampler(s): Rush Analysis(surcharge will apply): <br /> ❑ New Customer Customer Number:3- 1 S 0_:' ) ^ ❑S Day 04 Day 03 Day 02 Day ❑24 hour <br /> Address: /a / �— Rush pre-approved by lab: <br /> r (` g � $ - Comp Sampler Set up Date: Time: Electronic Data Transfer:❑ <br /> es Ono <br /> Phon%!-'/ ;'37 5J*? <br /> Fax: Time: Mileage: If yes,To:State Client Other <br /> E-Mail: -7Shipping Charge:—..—Pickup Charge: Lab number: I <br /> Project name: �S/ q �� /14;• t <br /> Contact person: <br /> Billing Information(if different from above) a, = o <br /> ¢ _ O 2 = <br /> Name: <br /> Address: ° u 401 3 s0- p <br /> rnx o o <br /> o c3 n � Z <br /> fO rn a <br /> .. m c ° 5 <br /> Phone: Fax: ° oo ,° a o w T <br /> > <br /> 1 <br /> E-Mail: a ,- o �^ N a <br /> n o s m �' cc 0- + z <br /> Contact person: o o; o z ,o <br /> -0 LLJ <br /> Purchase order/contract/FGL quote number: a v z N Z Z 7 <br /> Monthly❑ Weekly❑ Quarterly❑ o g i ?y to j <br /> Pre Log Required:yes Frequency: Other❑ ,. ? c a -1 d N v <br /> v, ° U o an x }' <br /> INFORMATIONSAMPLE 1 0 o ¢ � � 3 _ tz v > <br /> Sample Location/Description Date Time 0- E 0-O t° 3 �° � 0 w = z 1 <br /> Number Sampled Sampled Z a u l7 v, , v a tr d <br /> v�� an �'� ����, L 2 <br /> CUSTODY' REMARKS SECTION V <br /> e <br /> ,t Krlin pio d I a Q'+t7 i 1.,tier terms and coudltlon5 on! e r/eyirse of this docu at: �...1 <br /> U '/Y �/L�[ Q 1 ((� J ` Dule: /rJ Tbn Relinquished f : fimr: <br /> KeF'e -edb Dale: / `� Thne: Received _ Ut Tlmr: <br /> . " i Itelinquishcd by: Date: Tltne: Relinquished b — DpYYYYYtc:,--Tlme: <br /> ^1' ' IJV Timc: <br /> lI ReretvrJ by: Date: f{me: {tccelerd by: Date: <br /> Corpora' `'fives & Laboratory Office&Laboratory Offl, Laboratory Office&Laboratory Office iboratory <br /> 853 Cor :)n Street 2500 Stagecoach Road 563 Undo Avenue 3442 Empresa Drive,Suite D 9415% 0hen Avenue <br /> Santa PL CA 93060 Stockton,CA 95215 Chit, A 95926 San Luis Obispo,CA 93401 Visalia )3291 <br /> TEL: (805)392-2000 TEL:(209)942-0182 TEL:(530)343-5818 TEL:(805)783-2940 TEL: (5oy) 734-9473 <br /> CAv• 10119,999 ­77 1— .inn,— n.— cAv• icon,qAq gan7 GAY•/AnrN 7Rq.FJ019 FAX- 7'id-Rd AS <br />