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M01 = = m m =V� U*WUW ■At3iiii 14dW AMLYNW HOW JWRMW <br /> n <br /> $ 3334 Victor Court+Santa Clara CA 95054 <br /> IN.�Y (408)748 9700 FAX(408 7 SERVICER EST NO P O# `PAGE OF <br /> _tj ANALYSIS RQUESTED <br /> PROJECT NAME t+ ��f� r=PRESERVATIVE HO 1-10 HCI NP NP NP HCI HND NP H SD NaDH <br /> PROJECT MGRCID-- <br /> �� U� <br /> COMPANY u1 n, 0 <br /> ADDRESS <br /> L2 L L!f PHON OU Co Ov ��� ti��� 0 C�o Q m m co o r° <br /> LL „� <br /> FAX 0 ao a m m "Ti c iv <br /> Cr i <br /> � ro _Cp a2 0 <br /> SAMPLER'S SIGNATURE uo y C7ro �Q a'�m ° �' c U 0 <br /> m �,. roy 2 a c7 �� 00 2S aro <br /> SAMPLE LAB m Q ao m mU ate,Q .� I a ro U2 <br /> I D E TIME_771 D MA I Z J�co Zco �'QQ. �Z �� Q��' �p ��~° aQ 220 U� REMARKS <br /> � R U w-`3 rf 15� TPI <br /> 5#O? D iv - z <br /> MW 17— <br /> Oto M /000 v <br /> Stfd -D w - 110 <br /> 5v� to MwAk kMw- <br /> 5th t tint w -� <br /> NQUISHED BY RECEIVED BY NM&flrfflJ N RECEIVED BY TURNAROUND REQUIREMENTS REPORT REQUIREMENTS <br /> 1 da <br /> Signature Signature Signature Signature — 2 _3 tlay _ II Report(ncldes MS <br /> y _ day <br /> MSD,as required,may be <br /> Panted Name Panted Name Panted Name Printed Name — 5 day —Other charged as samples) <br /> Standard(10 worlong days) III Data Validation Report <br /> Firm Firm Firm Firm (includes All Raw Data) <br /> Results Due _ MDLsIPQLr)Trace# <br /> Date/Time Date/Time Date/Time Date/T rme Electronic Data Deliverables <br /> RELINQUISHED BY CEIVp SAMPLE RECEIPT Condition Custody Seals <br /> SPECIAL INSTRUCTIONS/COMMENTS <br /> Signature Signatu / Circle which metal� s erg to be analyzed <br /> Printed Name Panted T49memetals Al Sb Ela Be B Cd Ca Cr Co Cu Fe Mg Mn Mo Ni K Ag Na Sri V Zn <br /> J f As Pb Se Tt Hg <br /> Firm Firm 6i 6,T";� <br /> Date)Time Dateftirne <br /> Shipped Via/Tracking# Storage <br /> *Will sample results be used in connection with drinking water regulations> ❑ Yes ❑ No If yes you must so indicate by writing"DW"for each such sample <br />