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720 Olive Drive, Suite D <br /> .�� Davis,CA 95616 <br /> Lab:530.297.4800 <br /> ANALYTICAL cec Fax:530.297.4803 Lab No. V Page of <br /> Project Manager: Phone No.: <br /> Zoe s o m a e— Chain-of-Custody Record and Analysis Request <br /> Company/Address: FAX No.: t- For Lab <br /> ACI LIa t" F- 1tv f'r o 1i M ,ey-tq I Cs 16) 3 5f - I} !9 6 Analysis Request F use only <br /> Project Number: P.O.No.: Project Name: ia a I W.E.T.(x) <br /> Project Location: Sampler Signature: N '� <br /> TOTAL(X) Q <br /> liar,—11liqr,4-11 WA14 Stoc- k 'tck, $ _ � m Q <br /> T <br /> W W <br /> ContainerMethod o g o o N <br /> Sampling (Type/Amount) Preserved Matrix N g o a. a (10 � �r z <br /> o� <br /> M � co <br /> O c�lS � O X 20 2 c aci o o N c` <br /> N (0 CO N tl 0- Am <br /> Sample g LU 0 E W W x °' co m � N <br /> Designation Date Time v ai 5; T i v z 3 m 0 0 0 0, W W v N <br /> MW- ro z t-1100 lion X x W IX kI I X —v7 <br /> K W- J U to 4 Xx W x x X _0 <br /> V W W I D 1110 4 X )c w x x X -U3 <br /> VW —ID 1130 4 X X W X X X -'O� <br /> Wei( -# Z 1100 X W X X X - <br /> -FT- <br /> I �T 11 <br /> Relinquished by: Date Time Received by: Remarks: <br /> Rellnquished by: Date Time Received by: Email address: <br /> ❑.doc ❑.xis ❑.txt ❑other <br /> Relinquished by: Date Time Receh/qd by Laboratory Bill to: <br /> F,g1titAf hYti^Ch4`1 it►t �l <br /> `�-�----�----- 1 �'J f -�•a � p.�� �3 o X � ��I �u he k p M k ri�is 9 S��3 <br /> Distribution: While-tab. Yellow-File,Pink-Originator / COC.fhB(9198) <br /> d <br />