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a myrti-EMERY COMPANY CHAIN OFCUSTOD. ... D <br /> -^'Tire Full Sen-ice Independent Tesriug Laboratory,Esrabkhed 1904 ANALYSIS REQUEST <br /> 781 East Washington Boulevard • Los Angeles,California 90021 • (213)749-3411 • Fax:(213)745-6372 PATE: PAGE OF <br /> P.O.Box 880550,Hunter's Point Shipyard Bldg, 114 • San Francisco,California 94188 • (415)330-3000 • Fax:(415)822.5864 <br /> 5427 East La Palma Avenue • Anaheim,California 92807 • (714)693-1026 • Fax:(714)693-IO34 FILE NO. LAB NO. <br /> CLIENT NAME: t'",e r <br /> Cr-JVD NC/fr✓1 <br /> ~~ ANALYSES REQUESTED: REMARKS: <br /> �/� <br /> 1.101 <br /> PROJECT NAME: PROJECT NO, P.O.NO. <br /> ADDRESS: /� ( jr :!f I Z? /X i <br /> PROJECT MANAGER: P, �Jc�N��u PHONE#: FAX#: �—�—� w <br /> . rn <br /> SAMPLER NAME: i� L <br /> v 1Ce� n <br /> —14t t�e�[Pn ]v .� [Signature[Qw/e_ El <br /> TAT(Analytical Turn Around Time) 0=Same Day; 1 =24 Hour, 2=48 Hour, (Etc.) Q m <br /> c� o <br /> 0 <br /> CONTAINER TYPES: B=Brass,G=Glass,P=Plastic,V=Voa Vial,0=Other: coN m <br /> SAMPLE DATE TIME MATRIX CONTAINER cO cov SAMPLE CONDITION/ <br /> I <br /> NO. SAMPLED SAMPLED SAMPLE DESCRIPTION WATER SOIL LUME OTHER TAT i TTre COMMENTS: <br /> 4 <br /> I <br /> /v 1 F/0 2- �/ l� <br /> Relin wished y:iSignala and rimed Name Received By,36ignature and Printed Name) Date: Time: SAMPLE DISPOSITION- _ <br /> 1. Samples returned to client? YES NO <br /> elinquished By:(Signature and Primed Name] Received By:(Sig a and Printed Name[ Date: Time: <br /> 2. Samples will not be stored over 30 days,unless <br /> Relinquished By:(Signaluse and Primed Named Received By:(Signature and Printed Name) Dais: Time: additional storage time is requested. <br /> 3. <br /> SPECIAL INSTRUCTIONS: Storage time requested: days <br /> BY Date <br /> DISTF31BUTION:WHITE,YELLOW, PINK TO SECO—GOLD TO CLIENT <br />