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4�4v\"�*s <br /> CHAIN OF CUSTODY 1 LABORATOY ANALYSIS REQUEST FORM <br /> 1433 North Market Boulei ard,Sacramento,CA 95834 Service Request No Purchase Order #5301837 <br /> _sEMC0n (916)928-3300 FAX(916)928-3341 _ _ Lab <br /> Pro,)ect Name Don Rogers Analysts Requested <br /> Project Number 22613-100 001 0 <br /> Protect Manager Claudio Avila <br /> N OND <br /> Company EMCON ° 3 <br /> Address 1433 North Market Boulevard <br /> 0 a:. <br /> Sacramento,CA 95834 0 °v° <br /> Phone (916)928-3300 o w o <br /> FAX (916)928-33Go <br /> Sampler's Signature A z <br /> � REMARKS <br /> Sample Sample 1 Container I ypes <br /> ID Date Ttme I D Matrix HCl Preservations <br /> MW-1R tl ,M IZ3`T water 2 2 <br /> PSaturc <br /> QUI ED V REC D 81 RELINQUISHED BV RECEIVED BI< TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X 1 Routine Report <br /> agnaturc Signature Signature 24 hr 4a hr 5 day 11 Report(includes DUP,MS <br /> may,uired <br /> Starsdard(-10 15 working days) MSD,as required, �be <br /> Printed Name Pries d Name Printed Name Printed Name <br /> Provide Verba]Preliminary Results charged as samples) <br /> t t] Provide FAX Preliminary Results III Data Validation Report <br /> Firm FirmLvlfV Firm Firm Requested Report Dare (Includes All Raw Dasa) <br /> it 12,61%, 13' � l3SZ RWQCB <br /> Dat lme Date/Time Date/rime Date/rime (MDLs/PQLs/fRACEtt) <br /> RELINQUISHED BV RECEIVED BV Special Instructions/Comments Container Types Key <br /> 40 ml VOA 1 <br /> 125 ml LPE 2 <br /> Signature Signature <br /> 500 ml LPE 3 <br /> 1 1 iter HDPE 4 <br /> Printed Name Printed dame <br /> 500 ml glass S <br /> I Intl 1 iun I leer glass 6 <br /> 20 sls ring 7 <br /> Date/flme Date/Time glassjar 8 <br />