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TestAmerica San Francisco <br /> 1220 Quarry Lane Chain of Custody Record Test <br /> Amedca <br /> Pleasanton, CA 94566 711i-3.WYU-,to I7'?I&1R0NMC VTAL!�uM'NG <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 720-9455-1 <br /> Client Contact: Phone: E-Ma7: Page: <br /> Shipping/Receiving dimple.sherma@testemericainc.com Page 1 of 1 <br /> Company: Job#: <br /> KIFF Analytical Analysis Requested 720-29268-2 <br /> Address: Due Date Requested: M ';; Preservation Codes: <br /> 2795 Second Street,Suite 300, 7/15/2010 �t"1 A A-HCL Ni-hexane <br /> Gity: TAT Requested(days): i°L 3-NaOH N-None <br /> Davis C-Zn Acetate 0-AsNaO2 <br /> Stale,Zip: D-Nitrc Acid P-Na204S <br /> E-NaHSO4 Q-Na2SO3 <br /> CA,95616 ''�� F-McOH R-Na2s2s03 <br /> Phone: PO#: — G-Amchlor S-H2SO4 <br /> H.Ascorbic Acid T.TSP Dodecahydrate <br /> Email: W09.1 9 I-Ice U-Acetone <br /> �. J-DI Water V-MCAA <br /> ° m W- <br /> Project Nama: Project#: s `" '= <br /> K-EDTA ph.4-6 <br /> Nestle-Ripon 72000256 . U L-EDA Z-other(specify) <br /> O <br /> Site: SSOW#: °ui Other: <br /> U <br /> Sample Matrix <br /> TYP e (W-wa er, Z <br /> s solla, iti 0 <br /> td Sample (C=comp, o ,we[, M <br /> N <br /> Sample Identification-Client lD Lab IDJ Sample Date Time G=grab) BT-TIM..A-A,rai Special Instructions/Note: <br /> •zr z Y - t4 °3 3 �.- i "€ " a a arii-�s -'u s. m> - # <br /> N1400 MOM, <br /> 5725 HALL 2009-130(720-29268-4) 7113110 Pa' Water X <br /> t'( <br /> ific <br /> O 5725 HALL 2009-140(720-292614:40 8-5) 7113110 Water X :3r <br /> i-h Pacific ��sP <br /> N 5725 HALL 2009-150(720-29268-6) 7113110 P15:35 Water X <br /> 5725 HALL 2009-160(720-29266-7) 7113110 Pacific Pa ifiWater X <br /> E <br /> 2� <br /> :4�Lis3i <br /> }1 s€r <br /> Possible Hazard Identification Sample Disposal(A fee may be assessed if samples are retained longer than 7 month) <br /> ©Non-Hazard ©Flammable ©Skin Irritant © Poison 8 Unknown © Radfoiogical Return To Client ©Disposal By Lab Archive For Months <br /> Deliverable Requested:t,it,Ill,iV,Other(specify) Special Instructions/QC Requirements: <br /> v <br /> Empty Kit Relinquished by: Date: Time: Methodo€shipment: <br /> Rellnqulshed by: t2s1 e T Coma Received by: DatetTime: Company <br /> O [j <br /> Relinquished by: gate ima: Company Received by: Datefrime: Company <br /> G) <br /> Relinquished by: OaterTime: Company Received by: DatelTime: Company <br /> Custody Seals intact: Custody SealNa Cooler7e nperat tre(s) C and Ocher Remarks: <br /> A'' Yes ' a No <br />