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{ Uy�45 <br /> CHAIN OF CUSTODY / LABORATORY ANALYSIS REQUEST FORM <br /> Shaw Environmental&Infrastructure,Inc Purchase Order <br /> 1326 North Market Boulevard,Sacramento,CA 95834 Lab CLS Labs <br /> Project Name Parkinson's Arco,Stockton Analysis Requested <br /> Project Number 8800401A/01060000 _ <br /> Project Manager David Herzog - c _ <br /> Company Shaw Environmental& Infrastructure,Inc. <br /> Address 1326 North Market Boulevard <br /> Sacramento,CA 95834 0 ' °O,, <br /> Du Ph (916)565-4367/ E (916)56 56 s1 rA�i <br /> Sampler's Signature J:� w µ <br /> REMARKS <br /> Sample LAB Sample 1 Contatner Types _ <br /> I D Date Time I D Matrix - HCl Preservations <br /> MW-I �.Z 03 Water— 4 I 4 _ <br /> MW-2 - t Water 4 I 4 <br /> MW-3Water 4 I 4 <br /> MW-4 1024 Water 4 I 4 - - <br /> _ i <br /> MW-5 10* Water 4 4 _ <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND - REPORT REQUIREMENTS - <br /> A A4 REQUIREMENTS X I Routine Report <br /> Sign r Sig t Signature Signature 24 hr 48 hr , s day II Report(me udes DUP,M5 <br /> (YfWI C,L X Standard(-10.15 working days) MSD,as required,may he <br /> P n d Nam!¢a , Printed Name Printed Name Printed Name Provide Verbal Preliminary Results charged as samples) <br /> Provide FAX Preliminary Results III Data Validation Report <br /> Fl � Firm Firm Firm - Requested Report Dare (includes All Raw Data) <br /> y* - - RWQCB _ <br /> Date/Time (-1{+.3 DatelTime I lip Dater ime Date/Time - (MDLs/PQLs/TRACE#) _ <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Coin mcuts Container Types Key <br /> 44 m!VOA l <br /> Signature Signature Need EDDs as required by the RWQCB CLS Labs 250 ml LPE -2 <br /> 3249 Fitzgerald Road 500 ml LPE 3 <br /> Printed Name iPrinted Name Reporting limit 5ppb for MFBE Rancho Cordova,Ca 95742 - 1 liter HDPE ---4 <br /> 916-638-7301/Fx 638-4510 500 ml glass 5 <br /> Firm Firm Contact Ray Oslowski 1 liter glass 6 <br /> 2x6 g 7 <br /> Daterfime Date/Time glas 8 <br />