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CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> SHAW Environmental&infrastructure,Inch Purchase Order 189247 for 2002' <br /> 1326 North Market Boulevard,Sacramento,CA 95834 Lab Sparger Technology <br /> Project Name Don Rogers Analysts Requested <br /> Global ID No 70607700717 <br /> Project Number 8800391A/0105 o <br /> Project Manager <br /> Company SHAW Environmental& Infrastructur ,In <br /> Address 1326 North Market Boulevard o <br /> Sacramento,CA 95834 4 o <br /> Dir Ph 916-565-4370 1 FAX9 6-565-435 ° <br /> Sampler's Signature a, F <br /> z H REMARKS <br /> Sample LAB Sample ] Container Types <br /> I D Date Time I D Matrix HCI Preservations <br /> MW-IR water 3 3 <br /> water > > <br /> VW-2D 0!Z water 3 3 <br /> VW-3D ? water 3 3 <br /> RELI DISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X 1 Routine Report <br /> S1 a Sl gna a Signature Signature 24 h. —48hr 5 day Il Report(includes DUP,MS <br /> Z Sundard(-10.15 workmgdays) MSD,as required,may be <br /> PrVed N e I Printed Name G' Printed Name Pnnted Name Pmde Verbal Preliminary Results charged as samples) <br /> ✓� r� �4\.L iff1 2 c Provide FAX PreliminaryRcsulu M Data Validation Report <br /> Ft Firm Ftmt Firm Requested Report Date (includes All Raw Data) <br /> RWQCB <br /> Date/time Date/Time Q Z,fZ atv Timc Date/Time (MDLs/PQLsfrRACE#) <br /> REL Q SITED BY RECEIVED BY Special Instructions/Comments Container Types Key <br /> Sparger Technology 40 ml VOA 1 <br /> Signature Signature 3050 Fite Circle,Suite 112 125 ml LPE 2 <br /> Need EDDs per RWQCB Requirement for UST sites Sacramento,Calif 95827 500 ml LPE 3 <br /> Printed Name Printed Name 916-362-8947/Fx 362-0947 1 liter HDPE 4 <br /> Contact Will 500 ml glass 5 <br /> Firm Finn 1liter glass 6 <br /> DaWrime Date/Time s ring 7 <br /> ar 8 <br /> am M M M id <br />