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TestAmerica San Francisco �1 Test medc <br /> 1220 Quarry Lane Chain of Custody Record � q ri q q <br /> Pleasanton, CA 94566 ,__: . . 1Pk'3r .. a, , <br /> Phone(925)484-1919 Fax(925)600-3002 <br /> Sampler: Lab PM: Carrier Tracking No(s): COC No: <br /> Client Information (Sub Contract Lab) Sharma,Dimple 720-9895.1 <br /> Client Contact: Phone: E-Mail: Page: <br /> Shipping/Receiving dimple.sharma@testamericainc.com Page 1 of 1 <br /> Company: Job#: <br /> KIFF Analytical Anal sis Requested 720-30323-1 <br /> Address: Due Date Requested: «,Preservation Codes: <br /> 2795 Second Street,Suite 300, 9/20/2010' A-HCL M-Hexane <br /> City: TAT Requested(days): B-NaOH N-None <br /> Davis C-Zn Acetate 0-AsNa02 <br /> 0-Nitdc Acid P-Na2C4S <br /> State,Zip: <br /> O4 0 <br /> CA,95616 F-McOHR-Na2S2SO3 <br /> Phone: PO#: G-Amchlor S-H2SO4 <br /> C4 H-Ascorbic Acid T-TSP DDdecahydrale <br /> Email: WO#: h 1-Ice U-Acetone <br /> J-DI Water V-MCAA <br /> K-EDTA W- <br /> Project Name: Project#: L) 9 4-5 <br /> O .. L-EDA Z-other(specify) <br /> Nestle-Ripon 72000256 <br /> Site', SSOW#: _ Other: <br /> Sample Matrix <br /> Type (w•w,ur, o s <br /> s olid, q <br /> N Sample (C comp, o stereo, Special o e <br /> W Sam le Identification Client ID Lab ID Sample Date Time G rab eT T1 ut clallnstructtons/N t A.Air ' N <br /> _ m €? y re's <br /> sad <br /> ~ 7501 KIERNAN 2008 EFF(720-30323-1) 9/7110 07:50 Water X <br /> ifi <br /> 7501 KIERNAN 2008 MID(720-30323-2) 9/7/10 07:54 Water X Q 2 <br /> I�h <br /> Pacific <br /> F� 7501 KIERNAN 2008 INF(720-30323-3) 9/7/10 07'58 WaterX 015 <br /> Ln Pacific 11 <br /> 5725 HALL 2009 EFF(720-30323-4) 9/7/10 P08:1f Water X �{ <br /> , <br /> 5725 HALL 2009 MID(720-30323-5) 9/7/10 Pacifi8:1fi Water X F 05 <br /> 08.21 <br /> 5725 HALL 2009 INF(720-30323-6) 9/7/10 P ifi Water X 06 <br /> 08:26 Water X &m . <br /> TB-090710(720-30323-7) 917110 Pacific <br /> r <br /> Possible Hazard Identification Sample Disposal(A fee may be assessed if samples are retained longer than 1 month) <br /> =Non-Hazard 0 Flammable Skin Irritant Poison B Unknown Radiological =Retum To Client 0 Disposal By Lab Archive For Months <br /> Deliverable Requested: I,II,III, IV,Other(specify) Special Instructions/QC Requirements: <br /> D) <br /> iQMethod of Shipment: <br /> CD Empty Kit Relinquished by: Date: Time: <br /> Relinquished by r' Daterrime: Company Received by: Daterrime: Company <br /> 0 <br /> O <br /> Relinquished by: Date rime: Company Received by: Date/rime: <br /> W <br /> Relin y: Daterrime: Company Received by: Daterrime,�a�/� �'�O -QmRagY L� <br /> �. l IV A .� <br /> Custody Seals Intact: Custody Seal No.: Cooler Temperature(s)°C and Other Remarks: <br /> A Yes A No <br />