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! ! H O ! ! ! ! ! ! ! ! ! ! ! <br /> C7STODY / LABORATO�ANALYSIS REQUEST FORM S <br /> =• <br /> IT CORPORATION- 1326 North Market Boulevard,Sacramento,CA 95834 Purchase Order <br /> Project Name Parkinson's Arco,Stockton Lab CLS Labs <br /> Project Number 880-0401A/01060000 Analysts Requested <br /> Project Manager Kathleen Waldo <br /> Company IT CORPORATION o_oo W <br /> Address 1326 North Market Boulevard 5 y' $ <br /> Sacramento,CA 95834 c °� w <br /> Dir Ph (916)565-4370 / FAX 6)565-4356 U x <br /> 4. <br /> c � <br /> co A <br /> Sampler's Signature x W W <br /> Sample LAB Sample— I REMARKS <br /> ID Date Ttme I D Container Types <br /> Matrix HCl <br /> MW-1 -1t9ty Water 4 4 Preservations <br /> MW-2 Water 4 4 <br /> MW-3 °1 Water 4 4 <br /> i <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> Si natur REQUIREMENTS X I Routine Report <br /> g Sign u Signature Signature 24 hr 48 hr 5 day II Report(includes DUP,MS <br /> PrintedCL� <br /> a Pnn d ami s.d.rat-iais workinsd.ys) MSD,as required,may be <br /> �� 5c q Printed Name Printed Name <br /> Plourde Verbat Preliminary Raulu charged as samples) <br /> FirmFirm Firm Provide FAX PretimmaryResutq III Data Validation Report <br /> ew— Firm Requested Report Deis (includes All Raw Data) <br /> Date/time RWQCB <br /> l�'—{L Date/time I DatelTtthe Date/time (MDLs/PQLs/IRACEq) <br /> RELINQUISHED BY RE EIVED BY Special Instructioes/Comments <br /> Container Types Key <br /> Signature 40 ml VOA I <br /> g Signature Need EDDs as required by the RWQCB CLS Labs 250 ml LPE 2 <br /> Printed Name3249 Fitzgerald Road 500 ml LPE 3 <br /> Pnnted Name Reporting limit Sppb for MTB): Rancho Cordova,Ca 95742 I liter HDPE 4 <br /> FirmFirm 916-638-7301/Fx 638-4510 500 ml glass 5 <br /> Contact Ray Oslowski I liter glass 6 <br /> Date/Time .—;;; Date/time 2x6 sls ring 7 <br /> glass Jar 8 <br />