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TestAmerica San Francisco <br /> 1220 Quarry Lane Chain of Custody Record Test <br /> Pleasanton, CA 94566 MWOMM <br /> r�r.t_trs r rr. .zr� x� uT f,4- rt,rc <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-Mail: Page: <br /> ShippinglReceiving idimple.sharma@testamericainc,r-om Page 1 of 1 <br /> Company- Job#: <br /> KIFF Analytical Analysis Requested 720.29268-1 <br /> Address: Clue Date Requested: Preservation Codes: <br /> 2795 Second Street,Suite 300, 7126/2010 <br /> A-HCL M-Hexane <br /> City. TAT Requested(days); - B-NaOH N-None <br /> Davis C-Zn Acetate 0-ASN802 <br /> State,Zip: D-Nitric Acid P-Na204S <br /> CA,95616 E-NaHSO4 0-Na2SO3 <br /> Phone: PO#: j F-McOH R-Na2S2503 <br /> n , G-Amchlor S-H2SO4 <br /> V H-Ascorbic Acid T-TSP Dodecahydrate <br /> Emai€: WO#; I-lee U-Acetone <br /> ) ) J-pt Water V-MCAA <br /> Project Name: Project#: ' m � K-EDTA W-ph 4-5 <br /> Nestle-Ripon 72000256 L-EDA Z•other(specify) <br /> Site: SSOW#: _ Other: <br /> Sample Matrix <br /> Type (wawarer, 4 <br /> s-solea, <br /> b Sample (C-comp: o-tcrcli, ' m <br /> N Sample Identification-Client ID Lab ID) Sample Date Time G=grab) BT•Tl..,A-Air m0 � Special InstructjonslNote: <br /> U44 <br /> 4 'e €�.. -; <br /> N TB-071210(720-29268.1) 7/12/10 14:25 Water X <br /> Pacific <br /> 0 5725 HALL MID(720-29268-3) 7112170 14"40 Water X <br /> Pacific :; <br /> 5725 t I,EFF(726-A 2G 6-2) 7/)2 110 43� Wa a <br /> P' <br /> raP <br /> 'g6z <br /> ` <br /> �ek <br /> 3 . <br /> tl�j <br /> �3 <br /> �3FF <br /> Possible Hazard Identification Sample Disposal(A fee may be assessed if samples are retained longer than 1 month) <br /> =Non-Hazard ©Flammable ©Skin Irritant © Poison B Unknown Radiological =Retum To Client =Disposal By Lab © Archive For Months <br /> Deliverable Requested:1,11,III,IV,Other(specify) Special InstructionslQC Requirements: <br /> w <br /> ca Empty Kit Relinquished by' �_ Date: Time: Method of Shipment: <br /> m <br /> — Relinquished by: DM ! Com an Received by: Daterrime: Company <br /> cri <br /> Relinquished by: Dated me: Company Received by: Oate>rme. Company <br /> C),) Rciinqulshed by: Daterrime: Company Received by: Dateflime: Company <br /> CastodySealsantact: Gustody'SealNo.: Cooler Temperaturejs) Cand01herRemarks: <br /> A.Yes :d No <br />