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CHAIN OF CUSTODY OnIG!NAL <br /> www.fglinc.com AND ANALYSIS REQUESTDOCUMENT <br /> Client: Sampler(s): Rush Analysis(surcharge will apply): <br /> U,New Customer Customer Nu : �1,y)�/ 05 Day 04 Day 03 Day 02 Day ❑24 hour <br /> Address: mbs W—� <br /> Rush pre-approved by lab: <br /> Comp Sampler Set up Date: Time: Electronic Data Transfer:❑yes Ono <br /> Phone: ; 'D 2 x: Time: Mileage: If yes,To:State_Client Other <br /> E-Mail: DD ' Shipping Charge: Pickup Charge: Lab number. <br /> Project name: `I Il /� <br /> Contact person: �ti� MerQm I �� <br /> Billing Information(if different from above)J < A 7 <br /> Name: t? <br /> rn <br /> Address: Q ¢ o o <br /> o A S q 3 v N z 0 <br /> B m c o = <br /> Phone: Fax: d 'o o ° a p <br /> E-Mall: in <br /> J yd d + z <br /> m D <br /> Contact person: o <br /> Purchase order/contract/FGL quote number: o �`- e` a Z A ; v o E, z o a <br /> MonthlyO WeeklyO Quarterly(3 c S g 2 3 m i. d Z <br /> Pre Log Required:yes_ Frequency:Othero E v° C°C F ? vvry a N " L a � W> - W <br /> v O ..~- D �- <br /> .] <br /> g °`o o 0 _ g <br /> Sample Location/Description Date Time E �> a 3 3 3 LA u � F x <br /> Number Sampled Sampled z Z a vt t?3 : � v a a <br /> IWb d by..d..bj«t to tb.1--d...dut.o..o tbo r...r..or mu d......tt: �� <br /> D.t�Ti.,:-21%" .gal.h.d by:-��L S Do,.: Time: bL <br /> R...v.d by: D.t Tlm /y i4' R...Iv.d by: `J!W D.I.: Tlm <br /> R.11.q.l.bed by: D.h:�ilm.. 1 ..ogi.l.b.d by: D.,.: Tlm<: <br /> R.plred by: D.U: 71m.: /1�)///�/L/J.'J`�h.d by: <br /> orporate Offices 8 l-eboratory ce 8 Laboratory Om�&Laboratory Office&Laboratory Office&Laboratory <br /> 653 Corporation Street 500 Stagecoach Road 563 East Lindo Avenue 3442 Empress Drive,Sulte D 9415 W.Goshen Avenue <br /> Santa Paula.CA 93060 Stockton,CA 95215 Chico,CA 95926 San Luis Obispo,CA 93401 Vlsalla,CA 93291 <br /> TEL:(606)392-2000 TEL <br /> (209)942-0182 TEL:(530)343-5918 TEL:(806)763-2940 TEL:(559)734-9473 <br /> FAX:(805)525-4172 FAX:(209)942-0423 FAX:(530)343-3807 FAX:(805)783-2912 FAX:(559)734.8435 <br />