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mmmmmm <br /> • CHAIN OF CUSTODY / LABOR �`=Y ANALYSIS REQUEST FORM <br /> 5114W Envit on mental& Infrastructure, Inc Purchase Order # 189x46 for 2002' <br /> 1326 Not th Market Boulevard,Sacramento,CA 95834 Lab Sparger Technology <br /> PrcnleeI Name Don Rogers Analysis Requested <br /> Ptil12ct NLonber 8800391A/01030000 <br /> Protect Manager Kathleen Waldo 0 <br /> Cornpanv SHAW Environmental & Infrasrr acture, Inc <br /> Addiess 1326 North Market Bottle%ard <br /> Sacramento,CA 95834 0 <br /> I'llone 916-565-4370 / FA 916-565-4356 U <br /> t.- u <br /> a, <br /> cry <br /> S:ttnl�let's Signature C7 <br /> T <br /> Z REMARKS <br /> Sample LAB Sample 1 Container I y pes <br /> I D Datp Time I D Matrix 3 edl-tr Preservations <br /> iNFL vofot� Air 1 1 <br /> EFFL 01/Q Air 1 1 <br /> i <br /> i <br /> I <br /> RI 1 I\QulSIIED!31 RE LIVED!31 RELIN UISI-1ED BY -CEIIIED BY 1 URNAROUND RE110111 REQUIREillENI S <br /> REQUIRENIENTS X I Routine Report <br /> 5 a ,t SignatuN Signature ignatugel 24 tor 48 hr S day 11 Report(includes DUP,MS <br /> l Standard(-lalSworiingdays} MSD,as required maybe <br /> { itLd N 1115 Printed N im, Printed Name Trinted Namenn Pru,id,1 a W PrOminary A,y94 d chit,t.d as satiipks) <br /> o� � lt:C�`� Protide FAX Preliminary Results 111 Dail Validation Report <br /> I rrp L I'uttt l inn �� r1rm Requested Report Date (includes All Raw Data) <br /> �lY�it,/+i3 V `Ti zd -711)OZ r. f v RWQCt3 <br /> DitOTimc Dat /T me Date/time (MDLs/PQLs/PRACE#) <br /> RLC 1,\Q0ISIICD BY RECEIVED BY Special Instructions/Comments Container Types Key <br /> 40 nil VOA l <br /> Signature Sienature 125 nit LPE 2 <br /> Sparger Tech 500 ml LPE 3 <br /> Printt,d Namt, Printed Name 3050 Fite Circle,Ste 112 1 liter HDPE 4 <br /> Sacto,Calif 9.5827 500 nil glass 5 <br /> Ilrm 1 irm 916-362-8947/r\362-0947 1 liter glass 6 <br /> 2\6 sls rine 7 <br /> IDato-fl nnC Date/Time glass jar y 8 <br />