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� CSN �UWJD�Ar&W11Y"A1TSIS REQUEST FORM <br /> IT/ Er►ICOlf 1433 North Market Boulevard,Sacramento,CA 95834 Service Request No Purchase Order <br /> (916)928-3300 FAX(916)928-3341 Lab SEQUOIA J <br /> Project Name Don Rogers Analysts Requested <br /> Project Number IT#792773122613-100 003 <br /> Project Manager Mark Capps <br /> N <br /> Company IT/EMCON 0 <br /> Address 3939 Cambridge Road,Suite 220 <br /> Cameron Park,CA 95682 U <br /> Phone (530)676-6881 4- <br /> o <br /> > AX (530)676-6885071 <br /> Sampler's Signature 0 0 W co <br /> :3 � � REMARKS <br /> Sample LAB Sample 1 Container Types <br /> I D Date Time I D Matrix IICI Preservations <br /> MW-I R water 3 3 <br /> Lid— <br /> RLIt BYRECEIV RECEIVED BY TURNAROUND REPORTREQUIREMENTS <br /> REI II <br /> I Z�Mlll REQUIREMENTS X I Routine Report <br /> Sig u Signet Signature Signature 24 hr 4a hr 5 day 11 Report(includes DUF,MS <br /> p Staudud(-i0 15 workmg days) MSD,as required,may be <br /> Panted Printed Nam Printed Name Printed Name Provide Verbal Preliminary Results charged as samples) <br /> 1 i f Provide FAX Preliminary Results III Data Validation Report <br /> Firm 'f L r J J ��� Firm Firm Firm Requested Report Pae (includes All Raw Data) <br /> RWQCB <br /> Datcrrime Datefrime Datw Time Date/Time (MDLs1PQlsaRACEH) <br /> RELINQUISIiED BY ED BY Special Instructions/Comments Sequoia Analytical Container Types Key <br /> 819 Striker Ave,Ste 8 40 ml VOA l <br /> Signature Signe Sacramento,Ca 95834 125 ml LPE 2 <br /> 916-921-9600 500 ml LPE 3 <br /> Printed Name Pnnte lime Contact Rob Bobel 1 liter HDPE 4 <br /> 500 ml glass 5 <br /> Firm Firm r\ Ma ` l- NO 1 titer glass 6 <br /> L� 2x6 sls ring 7 <br /> Datefi coir, DateAriM /'1.1 glass)ar 9 <br />