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i <br /> CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> SHAW Environmental&Infrastructure,Inc. Purchase Order 208456 4 <br /> I326 North Market Boulevard Sacramento,CA 95834 Lab Sierra Analytical <br /> Project Name Don Rogers lysis Requested <br /> Project Number 8800391A/01020000 <br /> Project Manager David Herzog <br /> Company SHAW Environmental&Infrastructure,Inc. <br /> Address 1326 North Market Boulevard o <br /> Sacramento,CA 95834 U °� <br /> Phone 916-565-4377/ FAX 916-565-4356 o W <br /> Sampler's Signature <br /> � <br /> Sample LAB Sample REMARKSI! 1 E[ <br /> Container Types <br /> ID Date Time ID Matrix II Tedlar Preservations <br /> INFL jA Vapor 1 1[ 1 [[ <br /> EFFL i J Vapor 1 II 1 1[ <br /> II I[ <br /> II [[ <br /> II [[ <br /> II [I <br /> II I[ <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED II Y RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> %, C 11 1 REQUIREMENTS X 1 Routine Report <br /> fR <br /> Signature Signature II � Signature 24 hr 4s hr 5 day II Report(includes DUP,MS <br /> X standard(-10 15 workmg days) MSD,as required,ma} be <br /> d ame Printed Name Printed Name [ Printed Name Provide VerbalPrel:mmary Results charged as samples) <br /> Wright I Provide FAX Preliminary Results III Data Validation Report <br /> Firm Firm Firm I [ Firm Requested Report Date (includes All Raw Data) <br /> Shaw E&I Inc II RWQCB <br /> Date/Time ze��J; t?Db Date/Time Date/Time II [[ Date/Time Oh <br /> (MDLs/PQLs/'£RACE#) <br /> REL UISHED BY RECEIVED BY Special Instructions/Comr&nts Container Types Key <br /> \� 40 ml VOA 1 <br /> Signature Signature Sierra Analytical 125 m[LPE 2 <br /> Y26052 Merit Circle,Ste 105 500 ml LPE 3 <br /> Printed Name Printed Name Laguna Hills,Calif 92653 1 liter HDPE 4 <br /> 949-348-9389/Fx 348-9115 500 ml glass 5 <br /> Flan Firm �� �4 Ship Golden State Couner I liter glass 6 <br /> ��•, Y,1 Acct No 14365 2x6 s r 7 <br /> DatelTtme Date/Time J� 800-322-5555 glass 1 8 <br />