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ENVIRONMENTAL CHAIN OF CUSTODY -- FUSH <br /> AND ANALYSIS REQUEST DOCUMEN ORIGINAL <br /> 1 <br /> ohl�/�Ir �-�1 n� ` Rush Analysis: 5 Days 2 Days 24 hrs. <br /> Client: Fal (s): tms r�'Z <br /> Subject to surcharge <br /> Customer Number: QA/QC report required: yes no <br /> Address: <br /> Electronic Data Transfer: yes no <br /> ampler Set up Date: Time: If yes,To:State_ Client _ Other <br /> Phone: �j Mileage: Lab number: T �0J <br /> FAX: �+ / / <br /> Project name: — 1�1r1 WIQ �r� /)90/ C7 — C(�i'Y1 o d J Lab Loc: SP Ll STK ❑ VI ❑ LJ <br /> Contact person: Carrie— <br /> Billing <br /> arr)e--Billing Information(if different from above) <br /> Name: N li Q V <br /> N <br /> t� x i <br /> Address: a A <br /> a O " O W a p <br /> C; <br /> Phone: O m d E y z r / O <br /> FAX:_ U o � o o �' N w ^ <br /> Contact person: y 3 A U z Q �' ❑ <br /> + L4 <br /> Purchase order/contract/FGL quote number: d x O o ^ <br /> q U ani ® v°a E oe O M W z <br /> cc <br /> Pre Log Required: yes no .5 z H z z <br /> 73 <br /> CA 0 <br /> .o p <br /> Sample Location/Description Date Time ' Q" 3 rn y x ^ <br /> Number Sampled Sampled F z H c? cA w Cr) Go U <br /> or er "Mo n471_Com 5 /l�- 2 C NP SW <br /> PNnsw X <br /> N <br /> r <br /> t."� Reli s d by and Sect to the tern n onditions on the reverse of this documeennt:t 1 I Date 7 Time Relinquished by: v +../ Date Time <br /> Jq r <br /> Received by: . � Date'�/�'t9me/�l+� Received by: <br /> Relinquished by: GG Date ""a ( Time_ Relinquished by: Date Time <br /> Received by: 17J Date � / r.- Received by: Date Time <br /> CORPORATE OFFICE&LABORA OFFICE&LABORATORY FIELD OFFICE <br /> P.O.Box 272853 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:(8051525-4172 FAX:(209)942-(M23 — ""'—If 9415 <br />