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Request for Laboratory Services/ Chain of Custodv <br />Send Report To JoM IBisseln 'Hygeia Laboratories IInic. <br />39,24::Bfuebonnat Drive <br />,company Name ATC - Roseville 'r <br />f X rf Stafford, TX 77477 <br />(281),242-10,00 (281) 242-1030 Fox <br />Company Address 1929 County Road West <br />City, State, Zip 56113 Purchase Order No. <br />�Phionle ( 661 ) 635-9050 Fox ( 661 �635-9080 13111 To <br />1161f d-Warent fro., Sand Repod TO) <br />Client IProject No. 22.25172-10003 Task 1 Addirs�ss <br />Client Project Namie-City of Roseville Fire Station City, State, Zip <br />No. Sample Submitted.* 14 PhoneS.......) Fax _L)_ <br />TtirriarolundTime: rls'tandard (7-10 business days) 03-5 days I[948 hrs 024 hrs EJO hrs [] 3 hrs <br />R0120EI �kb BY.- Fax ...... Cell/Pager.( <br />Phone E-mail Bissen2Matc-enviro-cam <br />clommentstAidditionial InIlrUall,001; <br />Collected BY: Bissen Date: 11 -7-06 <br />IF <br />Z <br />D <br />Firefighter,Day 1510 L r. <br />.............. . ............................... .. <br />LJ <br />RSV-2 Z <br />D <br />D <br />............ 150 L <br />Basement I 50L <br />.......... <br />IL ................. r. ._......,._.._,.......- _....___ <br />.... ........ ...... . . ............. I .............................. ........... . <br />.............. <br />RSV-3 <br />Z <br />RSV-4 <br />Z <br />............ . .. ......... <br />. . ..... . ­­­­_1.-.­ ...... <br />........... <br />...... ------ ------- <br />. ........ __ ........... . ....... ...... <br />........... <br />.......... <br />. ........... <br />-- ----- <br />- -- ----- -- --------- -- ---- - - ­­­ <br />. ......... ........ <br />............. <br />.......... <br />1Z;-;Z0fon BIO=Bilocell BR=BurkhaW Mb Micro 5 GYDzGYdex-D fP=Impaollon Plate 60=66nitact'Piate T Tapo Sz;Swab BL=Bulk D=Dust W=Water <br />2 ST=$pore Trap D1=01rect Exam ot)=0luantitative iw;ect runo <br />Exam (Post-Remediallon Only) QF1100=0unntitative 1!3 Mediia 1pr=Fungal ID for IP <br />CPF=Furtgal ID foi DP MycA ;;A➢atoxia MycD=D8cxyai1va1eno1 (Voniltoxin) MYW=010ratoxin MycF=Furponlain MyoT=T-2 Toxin IPB=Bacterial 10 for IP <br />M13mBacterial Ilia Ifm CP O�1311OB3;;Cluairill(arivtSeCtei6aI U3 Media LIS=Usterfa sp. ENT=E?ileroWiclerlawae TCE; Jolal wiliformlE, icoli <br />:$TA;7; taphO000ccus aureus ALL=Allergan Panel <br />CIA <br />Mi <br />Sample Integrity: v.<-._1accept _.reject <br />Commots <br />L <br />0 <br />Hy9ela, IRefetence No. 002,22-o 603 z 0 No. Samples Analyzed: <br />Results reported by: <br />M) <br />m <br />Date JPG Ti: I /0L2�_ Initial Verbal Fax m <br />E-ail <br />Date Time Initials Verbal Fax P-ma <br />A <br />Date T[Me Initials Verbal Fax E-mail <br />J <br />tnv6ce No- Lo, Out Gate <br />9 .. . ........ .... ...... ..... . Lt <br />Relinquished By_(Si na •Time <br />1. %,.-A ---- ------ <br />We <br />RecqjIvelid y_(Signature) Time <br />IDate <br />rhasomple tafloctor is respon-siblaW r4lnisudng Jhzil W-1 ueirry!vs haya Sara prow-ved sword'Pg lo the opr.oprialto and app!`XaVlzvl° ' Form I. i A Re iv. 3 0310,912005 <br />C-9 <br />208925v4 <br />