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�'�►, � �.L►. .CST �-�'�I-� ���N� G�►�T�Y <br /> AND ANALYSIS REQUEST DOCUMENT <br /> 7pler . •Client: Rush Analysis: 5 Days _ 2 Days 24hrs <br /> Composite Sampler Setup: Subject to surcharge <br /> Customer Number: Date: <br /> Time: QA/QC report required: yes no <br /> Address: Subject to Surcharge Field Sampler: If yes, To: State Client _ Other <br /> Time Milage: <br /> Lab number: <br /> Phone: SAMPILE CONDITION <br /> � N M <br /> a Q FAX: Sample Temperature: Celsus <br /> � � m�a _ x <br /> o 0 <br /> sue° z <br /> ( )Leaking. ( ) Broken. ( )VOA Headspace <br /> Project name: <br /> 4 ° Custody Seal O yes O no <br /> a F e N z <br /> Contact person: o v ;� o • ' • <br /> =F z z o <br /> e 5 m a 33" rn x <br /> 1( <br /> E U 2 �3 <br /> )Ice Chest ( )UPS OWed Ex ( )Drop off ( )Other <br /> Ow <br /> Sample Date Time v o a° �'c 3 v z <br /> Number Location Description 4 =o a a 3 0 x ♦ ♦ • A Sample Sample z> 0. �?3 a <br /> i <br /> I <br /> CUSTODY <br /> Relinquished by:_ Date____Time Received by: Date Time <br /> --- Relinquished by: Date ____Time Received by: Date_ Time <br /> _ Relinquished by: <br /> __— ___..Datr- ___Time__ Received by: Date 'rime <br /> 3935 N. Coronado Ave. * Stockton CA 95204 * Telephone (209) 4 7 7-8105 * FAX: (209) 546-7497 * Email: jhvle@petallab.com * www.petallab.com <br />