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f r CHAIN OF CUSTODY 1 LABOR&RY ANALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 Service Request No Purchase Order <br /> aFilltO(1 (416)928-3300 FAX(916)928-3341 Lab SEQUOIA <br /> Project Name Don Rogers Analysts Requested <br /> Project Number IT#792773122613-100 003 <br /> Project Manager Mark Capps o <br /> Company 1T/EMCON CD <br /> Address 3939 Cambridge Road,Suite 202 <br /> Cameron Park,CA 95682 0 <br /> Phone (530)676-6881 � o^ <br /> FAX (530)676-6885 F" o <br /> 00 <br /> Sampler's Signature ,G <br /> z REMARKS <br /> Sample LAS Sample 611 Container Types <br /> D Date Time I D Matrix HCI Preservations <br /> MW-IR water 3 3 <br /> I <br /> I <br /> i <br /> RELI QUI 7YED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I Routine Report <br /> !%ture Slg re Signature Signature 24 hr 48 hr 5 day 11 Report(Includes DUP,MS <br /> Standard(-10.15 working days) MSD,as required,may be <br /> rented Name Pm[ Name Printed Name Printed Name Provide Verbal Preliminary Results charged as samples} <br /> Ira s <br /> Provide FAX Preliminary RcaulLS I11 Data Validation Report <br /> Firm Fir Firin Firm Requested Report Date (includes All Raw Data) <br /> W?lir /1 OO ;Ck_ RWQCB <br /> Date/time Date/ iigQ Date/time Date/time (MDLs/PQLs/rRACE#) <br /> RELINQUISHED BY RECUVE11 BY Special Instructions/Comments Sequoia Analytical Container Types Key <br /> 819 Striker Ave,Ste 8 44 ml VOA 1 <br /> Signature Signature Sacramento,Ca 95834 125 ml LPE 2 <br /> 916-921 9600 500 ml LPE 3 <br /> Printed Name Printed Name Contact Rob Bobel I liter HDPE 4 <br /> 500 ml glass 5 <br /> Firm Firm 1 liter glass 6 <br /> 2x6 sts ring 7 <br /> Date/time Date/time glass jar 8 <br />