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xilil CHAIN OF CUSTODY 1 LABORATORY? ANALYSIS REQUEST FORM Page_L Of / <br /> 1433 North Market Boulevard, Sacramento, CA 95834 ? Service Request No PO Number <br /> l <br /> EMCOn (916) 928-3300 FAX (916)928-3341 Is 9 a C)0? -7 <br /> Lab Columbia Analytical <br /> Project Name Teichert -Stockton Analysts Requested <br /> Project Number 20F90-002 007,Task 001 <br /> Project Manager Matt Turner <br /> Company EMCON -pinnacle <br /> ;Address 3939 Cambridge Road, Suite 202 <br /> I � <br /> Cameron Park, CA682 0 <br /> Phone (530) 676-68814. <br /> FAX (530) 676-6885 <br /> Sampler's Signature <br /> 7_ 1 I I I REMARKS <br /> Sample LAB Sample 1 Container Types <br /> I D Date Time I D Matrix HCI Preservations <br /> AS-] water 3 3 <br /> MW-14 water 3 3 <br /> I <br /> I <br /> *' ED BY RECEIVE BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I Routine Report <br /> Si atu° ��, f' `5 Signature Signiture241u as Its sddy I] Rcport(mcludcs DUi' MS <br /> YY N X Standard(—IO ISworlangdays) MSD as required maybe <br /> Print T�Jpr e� / Panted Nam Primed Name Printed Name Provrdr Verbal Prekmuwy Rcsulrs charged as samples} <br /> firm rr� Provide FAX Preliminary Results III Data Validation Report <br /> 'Q/��� ri ] Fig Fri Requested Report pale (includes All Raw Data) <br /> [ ( !1 RWQCB <br /> Date�Iime Date/Date/Time DatelTlme Datefllme (MDLsIPQLs/TRACEN} <br /> RELI\QL'ISHED BY RECEIVED BY Special Instructions/Comments L r+07 R z+ I D3 Container Types Key <br /> I Signature Signature 40 ml VOA 1 <br /> Columbia Analytical 250 ml LPE 2 <br /> 3334 Victor Court 500 ml LPE 3 <br /> Printed Name Printed Name <br /> Santa Clara,Ca l liter HDPE 4 <br /> Finn • 408-748-9700 nl glass 5 <br /> • Firm 0'er glass 6 <br /> Date/Time <br /> 2x6 s/s ring 7 <br />