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CHAIN OF CUSTODY 1 LABORATORY ANALYSIS REQUEST FORM <br /> SHAW Eavironmental&Inhaatructnre,Inc. Purchase Order- 208551 <br /> 1326 North Market Boulevard,Sacramento,CA 95834 Lab- Colambla Analyfi ai <br /> Project Name Don Rodgers Analysis Requested <br /> Global W, T06077007I7 <br /> Pro,Iect Nmnber SM91A/01050000 w <br /> Project Manager David Herzog ad <br /> Company- SHAW Environmental&Infrastructure,Inc. Q ¢ <br /> Address 1326 North Market Boulevard ra <br /> Sacramento,CA 95834 44 <br /> Dir Ph 916-565-4377 / FAX 16-565-4356 ° ¢ E <br /> Sampler's Signature GLu✓( z O �v, REMARKS <br /> ,r <br /> Sample 1AB Sainple Coy tamcr Typaa <br /> ID Date Time ID Matrix p HCI ins <br /> MW-211 uk-w f water 4 i1 (I 4 <br /> MW-3R /$Z& z water 4 11 4 <br /> MW-4RD �� 3 water 4 4 E <br /> MW-4RS ell wale ' 4 4 I <br /> E <br /> it II E <br /> 11 II <br /> MIN BY RECEIVED BY RELINQU111"BY11 RECEIVED BY TMA—ROUND IiElflRT RF,tj;71�iTS <br /> REQUIREMF.M'S X I Routine Rtpodt <br /> S Si Stgre (I S,B� 241W 43 Ir s ay 11 Report{includes DUP,MS <br /> sn,a a(-tats womfm&r) pkp MSD,as requnud,may be <br /> Ntune Name lPrwb:dName Printed dame nonan vwb.i Pr0=muy Rm1ft € dwged s sarVI-S) <br /> � !' �L 2— 11� II t FAX rr��nFr�rte�� WData Valydatrort Repair � <br /> Fern GT..G � .�f�}'�/�i�/�.�4�'�'� Firm II F'tr�rs► roa>t�>xc� � �ncludrs all IlawDffi� <br /> ItwQCa <br /> Date/rum > Datef ime �} r�0,3 /c? Datelrirnc 11 11 jDaWTIMC (1+�Is�PQLs/1 ne ? <br /> RFI INQUISHM BY RECEIVED BY Special Instract<ons/comments I Container Types Key <br /> i Columbia Analytical 40 ml VO& I <br /> Signature (i SM Caterpillar Road 125 nil LPE- 2 <br /> Need EDDs for lfGeoTral cker Redding,Cala 96003 f 500 tal LPE. 3 <br /> Naaw Prmted Name Report to the P bL in PDF format,piease. 530-244-5227/Fx 244-4109 { 1 lttrs HDPE 4 <br /> <Aavtd-HetzoBQSha . P cotn> Contact Karen Sellas 500 Illi em, 3 <br /> Firm pf ( Ship ria Golden State I liter glass 6 <br /> Acct 13171 W S/Ld= 7 <br /> _ d Shalaagli 7 800- 5140 8 <br />