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��- CHAIN OF CUSTODY / LABORAORY ANALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 Service Request No Purchase Order <br /> EMC011 (916)928-3300 FAX(916)928-3341 Lab Sparger ``ZZ <br /> Project Name Don Rogers Analysts Requested <br /> project Number 22613-100001 <br /> Project Manager Claudio Avila N <br /> Company EMCON o_CD <br /> Address 1433 North Market Boulevard <br /> I Sacramento,CA 95834 0 <br /> � <br /> Plione (916)928-3300 U L <br /> !FAX (916)928-3341 F <br /> r <br /> !Sampler's Signature <br /> z FA" REMARKS <br /> Sample LAB Sample l Container lypLs <br /> D Date Time I D Matrix HCI Preservations <br /> MW-IR 0-3 7 water 2 2 <br /> RLI l\QIIISiiED BI RECEIVE REi ljN7 D Y HERECEIVED BY TURNAROUND REPORT'REQUIRENIEN IS <br /> C REQUIREMENTS X I Routine Report <br /> Signaiur Mgnature Sigriature / fSlgn51ze 24 hr 48 hr 5 day II Report(includes DUP MS <br /> J <br /> /` Arrl e- / �' W, c�Q�r r Standard(-10 15 working days) MSD as required mai be <br /> 11 led Nam Printed Name Printed Name Printed Name Provide Verbal Prelominary Results chargLd as samplts) <br /> r t r;o C1 // (�(� (fir / Pf)Y Provide FAX Preliminary Results III Data Validation Report <br /> i innI irm Flrm f irm Requested Report Date (includes All Ra%% Dala) <br /> 7— ?o, 2 7579 11 �d RWQCB <br /> Dati.ffirne 5 7 67 Datef ii a Datfrtme Datefrime (HDLs/PQIsfIRACI-4) <br /> RELINQUISIIED B1 RECEIVED BY Special Instructions/Comments Container types key <br /> 40 ml VOA I <br /> tii,nalur� Signature 12i nil I ill 2 <br /> 500 nil I PI 3 <br /> !'nntcd Nam. Printed Name I Iilex 111)11 4 <br /> 500 1111 glass i <br /> r irm Firm I hicr glass 6 <br /> 2x6 sls ring 7 <br /> Diteffmit Date/Time glassjar B <br />