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Own <br /> 1♦ L� t♦ 1♦ <br /> CHAIN OF CUSTODY / LABORATORY ANALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 Service Request No Purchase Order # Page I of I <br /> €moon (916) 928-3300 FAX (916)928-3341 Lab <br /> Project Nallle 'Dt,01Z0V66'05 Anal sis Requested <br /> Proaec[ Number "1 3-100 .01 1) 1 ti �0 <br /> Project Manager Claudio Avila L N 01-1% <br /> Company Eh1CON n %,.J +^ <br /> Address 1433 North Market Boulevard 2 <br /> Sacramento,CA 95834 v td�3+ DEQ <br /> Phone (916) 928-3300 <br /> FAX (916)928-334 ,� j PQ <br /> Sampler's Signature arx E Ate- s <br /> REMARKS <br /> Sample LAB Sample <br /> ID Date Time ID Matrix <br /> -20 s-B l e- q <br /> _Z5-t-32� Y v <br /> I <br /> I <br /> RNI U1SHED BY R IVED BY RE[INQUISIILD BY RECEIVED BY TURNAROUND REPORT REQUlttt Nil N rS <br /> vL/XIS F E S RI,QIIIR1Nt1'NT% I Routine Rtpon <br /> Slure t Signature Signature 14lu 4a� V sday 11 Ri-pon UnLlud�a DUP MS <br /> r7j standard working days) MSD as required maybe <br /> L-1 ludl C1Pnnled Name Panted ame Pnnled Name Panted Name Provide Verbal Prehnunary Results charged as sample+) <br /> b�.A'u U"� ��� Provide I-AX Prcbmmary Result: III Dara Valydauort <br /> on Rep <br /> huI vp Fmn9 p F roil Firm Re—t <br /> d Repos Date (inrludi,All Rrw D real <br /> Z1!i ` 4�I?b RWQCB <br /> Daic)Tirnc Date/Time 0 Datelfune Daidrune (MDL&Wl-S/TRACErt) <br /> VLL <br /> RI I INQUIStit,D BY RI EI"D BY Special Inil rut,liondl.omments ConiamerType%Key <br /> 40 nil VOA I <br /> Signature Signature 125 nil LPE 2 <br /> SW ml LVE 3 <br /> Pnnled Name Permed Name 1 filer HDPE 4 <br /> 5118 ml glass 5 <br /> Flrin Firm I [tier glass 6 <br /> 20 s/s ring 7 <br />