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www.fglinc.com CHAIN OF CUSTODY ORIGINAL <br /> D AND ANALYSIS REQUEST DOCUAXNT <br /> Client7A, Sampler(s): Rush Al lysis(surcharge will apply): <br /> 0 New Custom er Customer <br /> Number..3—/9d 9I /�aAc, 0S Day 04 Day 03 Day 02 Day 024 hour <br /> Address: 0461 J2 Xyef •/'✓ Rush pre-approved by lab: <br /> —/rx d•I CA -T53-77 Comp Sampler Set up Date: Tini Electronic Data Transfer.Oyes Ono <br /> Phorl.i 4 9G6 Fax Time: Milea e: if <br /> E-Mail- y7 3 . 007y, Shipping <br /> yes,To:State_Client_Other <br /> Shipping Char e:_Pickup Charge:_ Lab number. <br /> Project name: 07 . T AO Iva <br /> Contactperson: lWTdi m w <br /> Billing Information(if dlfferentfrom above) a3o: a U <br /> Name: —3 0_ 3 E <br /> Address: a rnx 0 3 p d o t <br /> i0 <br /> c <br /> Phone: n <br /> Fax: ,m, m o S' o '•a' ¢ v a (W„ <br /> E-Mail: i puS t <br /> Contact person: o e c?' d <br /> t _ n In 1 <br /> Purchase order/contmct/FGL quote number. o. 6 d i ;, '3 w 0 e, i o" W w <br /> MbnthlyD WeeklyD DuarterlyD c c F i ?�'3 v' r �' <br /> Pre Log Required:yes_ Frequency:otherD E 8 H^ ? <br /> ransunaaaw <br /> Sample Date Time o <br /> Locauon/Descdption 3 3 3 o a <br /> Number Sampled Sampled F i F> E N t? ' g CI <br /> f00' •00 anm mmee bt.. e , <br /> CUSTODY <br /> / m.re nnir mr.m.m: <br /> nm.: )� R.wa.bem N: OILS <br /> pa.: I/3nm.: <br /> /✓0 -J'$•00 Re.n..e nr: ua.: +. nm.: / /O R.anm nr: Ti .: <br /> �) lN1 or R.II.yu1.b.0 br: p.l. WZ� Tm.:�R:Iu,,bb,d br: b.u: Time: <br /> �9dL <br /> R,,.Ind bts be:e: a b�mm� / R.telntl br: ane TI.0 <br /> Cemarnts ounces a LeberMary ounce a Laboratory Omce a.Laboratory Ornca a laboratory Omce 8 Lebantory <br /> 853 Carpe,elien 6traet 2600 Sta9ewean Read 563 East Linda Avenue 3042 Empresa Drive.Suite D 9615 W.Gaehen Avenua <br /> Santb Peule,CA 93060 Stockton.CA 95215 Chico.CA 95926 flan L.I.OClapo,CA 93x01 Meana,CA 93291 <br /> TEL(905)392-2000 TEL: 209)642-0182 TEL: 630)30&6918 TEL: 605)79&2940 TEL:(559)]3194]3 <br /> FAX;(006)62541]2 FAX: 209)942-0023 FAX: 530)343-0907 FAX: 605)79}2912 FAX:(559)730-6636 <br />