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ARCHIVED REPORTS_XR0011862
EnvironmentalHealth
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EHD Program Facility Records by Street Name
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F
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F
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5491
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3500 - Local Oversight Program
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PR0545028
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ARCHIVED REPORTS_XR0011862
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Entry Properties
Last modified
12/6/2019 5:37:33 PM
Creation date
12/6/2019 4:47:21 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
3500 - Local Oversight Program
File Section
ARCHIVED REPORTS
FileName_PostFix
XR0011862
RECORD_ID
PR0545028
PE
3528
FACILITY_ID
FA0003919
FACILITY_NAME
VAN DE POL ENTERPRISES
STREET_NUMBER
5491
STREET_NAME
F
STREET_TYPE
ST
City
BANTA
Zip
95304
CURRENT_STATUS
02
SITE_LOCATION
5491 F ST
P_LOCATION
99
P_DISTRICT
005
QC Status
Approved
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SJGOV\wng
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EHD - Public
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ALIFORNIA ]LABORATORYERVICES CHAIN OF CUSTODY �a �—� <br /> CLS ID. NO. <br /> Report To: Client Job Number ANALYSIS REQUESTED FIELD CONDITIONS: <br /> T T T T B 5 <br /> Name: Apex Envlrotech, Inc. No: ERA02.004 P P P P T, o T <br /> Street <br /> Address: 11244 Pyrites Way Destination Laboratory H H H H E X <br /> City,State, g d m k X y B <br /> and Zip: Gold River, CA 95670 <br /> X CLS (916) 638-7301 8 o e g <br /> Projec <br /> Name` Moore Petroleum 3249 Fitzgerald Road sr"„ 8 0 8 r 8 e <br /> Rancho Cordova M 0 1 0 O 0 n COMPOSITE: <br /> Manager:c SR CA 95742 1 5 1 s 2 a Y <br /> a <br /> Contact Contact C 5 5 e 0 t g <br /> Phone: ( 916 )851-01741 Pax: 916)$51-0177 ❑ OTHER cM n e 2 <br /> Sampled <br /> By: e S 6 <br /> Descri tion: 4th QMR water 8 <br /> $ <br /> Site 1 2 TURNAROUND SPECIAL <br /> Location: 5491 F Street, Banta TIME IN DAYS INSTRUCTIONS <br /> S 6 . <br /> DATE TIME SAMPLE CONTAINER 0 1 2 5 10 *DL for MTBE <br /> IDENTIFICATION MATRIX NO. TYPE 1.0 ppb for <br /> mess CWei V D6),— x Domestic <br /> act well <br /> Altemate ID: <br /> 3 toMW_ 1 <br /> VSECTEDOCOZZ ENTS SAMPLE RETENTION TIME PRESERVA�1-1 )HCL {3}=C LD. <br /> - 2} O (4) <br /> A <br /> REL SHED I3Y(SIGN) PRINT NAM /COMPANY D E TIME RECEIVED (SIGN) P TAME/ OMP NY <br /> J <br /> RE D AT L BY DATE/TIME: CONDITIONS <br /> rn 1 v 040 COMMENTS: <br /> SHIPPED ❑ FED EX ❑ UPS ❑ OTHER r AIR BILL# <br />
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