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ENVIRONMENTAL AND OF CUSTODY <br /> AND ANALYSIS REQUEST DOCUMENT ORIGINAL <br /> to]tAl am <br /> Client: F��yl/c r� ( 1 /� [Lab <br /> h Analysis: 5 Days 2 Days 24 hrs. <br /> Sampler(s); of ! Qm - Subject to surcharge <br /> Customer Number: ! <br /> D . /� /QC report required: yes _ no <br /> Address: P D • 6c) 53L / ctronic Data Transfer: yes _ no _ <br /> n ooC /��Q � Comp Sampler Set up Date: Time: _ <br /> 2 L7 I �� _ 2 es,To:State_ Client _pother <br /> Phone: j f ( <br /> FAX: (2-C>41) I �u - I�� Time: Mileage: number:Loc: SP ❑ STK ❑ VI ❑ ❑ <br /> Project name: "C /-`-' <br /> Contact person: CAa rrilf�— <br /> Billing Information(if different from above) <br /> Name: � � � nr <br /> b <br /> Address: <br /> 0 p u 0 3 n a O p <br /> s 3 0 3 Z <br /> Phone: C7COD <br /> `o _ o H N o ► 4 ,O <br /> FAX:_ v a az � H A (( �. <br /> Contact person: a ® A A a a + Z W (n <br /> Purchase order/contract/FGL quote number: c 4 tj c vEn F 0 � W Z <br /> 0 <br /> O <br /> PreLogRequired: yes no B Z Z z <br /> ` mb <br /> ^4 <br /> = T O . x_ ws <br /> ^• <br /> W1 0 <br /> 46 '2L <br /> G <br /> Sample Location/Description DateTime Q" 3 3 a �� Z ,j <br /> Number S mpl d Sampled E• z [– d t? rA m" t: ¢' `' V <br /> g. ( C riP K <br /> t t, '1 ! P NPJAZ <br /> Relin n ed by and bject to the to conditions on the reverse of this documene <br /> ' <br /> GrR <br /> Dat �-/ Tir1x Relinquished by: Dale Time <br /> Received by: D /p G me - Received by: Date <br /> Relinquishe by: Date "/,t -/� Time Relinquished by: Dale Time <br /> J Received by: Dateg11me Received by: Date Time <br /> CORPORATE OFFICE&LABORA OFFICE&LABORATORY FIELD OFFICE <br /> P.O.Bos 2721853 Corporation Street 2500 Stagecoach Road Visalia,California <br /> Santa Paula,CA 93061-0272 Stockton,CA 95215 Tel:(209)734-9473 <br /> Tel:(805)659.0910 Tel:(209)942-0181 Mobile:(209)737-2399 <br /> FAX:(805)525-4172 FAX:(209)942-0423 FAX(209)734-8435 <br />