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TestAmerica San Francisco "e'stmerica <br /> 1220 Quarry Lane Chain of Custody Record �'ZLY <br /> 5 <br /> Pleasanton, CA 94566 "r,I"VIR <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 720-11123.1 <br /> Client Contact: Phone: E-Mail: Page. <br /> Shipping/Receiving dimple,sharma@testamericainc.com Page 1 of 2 <br /> Job#: <br /> Company. <br /> KIFF Analytical Anal SIS Requested 720-33172-1 <br /> Address: Due Date Requested: �R;Preservation Codes: <br /> 2795 Second Street,Suite 300, 2115/2011 ;2 A-HCL M-Hexane <br /> City: TAT Requested(days): B-NaOH N-None <br /> Davis -fig. �a.7 C-Zn Acetate 0-AsNa02 <br /> D-Nitric Acid P-Na204S <br /> State,Zip: � . E-NaHSO4 Q-Na2SO3 <br /> CA,95616 F-McOH R-Na2S2SQ3 <br /> pO#: G-Amchlor S-H2SO4 <br /> Phone: r +'` H-Ascorbic Acid T-TSP Dodecahydrate <br /> Email: WO#: ` N eO= 1-Ice U-Acetone <br /> ' n <br /> J-DI Water V-MCAA <br /> K-EDTA W-ph4-5 <br /> Project Name: Project#: 0 L-EDA Z-other(specify) <br /> Nestle-Ripon 72000256 0 <br /> Site: SSOW#: Other: <br /> i= <br /> Sample Matrix <br /> (W-water, Z <br /> Type <br /> 3-:11d,nn 0 <br /> Sample (C=comp o— <br /> r r s m <br /> Sam le Identification Client ID Lab ID Sample Date Time G= rab eT T. a a N ° Special Instructions/Note <br /> x a s a�aF e �agg �t. <br /> .,$ •, '" : <gv. ` 'i +eA3..,,dam,. <br /> CD <br /> 15:45 .t, ; <br /> � TB-020111 (720-33172-1)0'0 2/1111 Water X <br /> v Pacific <br /> O 7501 KIERNAN 2008 EFF(720-33172-7) 2/1/11 14:45 Water X �Z <br /> Pacific <br /> (Jr!Cn 7501 KIERNAN 2008 MID(720-33172-8) 2/1/11 P4'4f Water X <br /> 7501 KIERNAN 2008 INF(720-33172-9) 2/1/11 14.51 Water XPacific <br /> Pacific5725 HALL 2009 EFF(720-33172-10) 2/1/11 14.22 Water X <br /> 5725 HALL 2009 MID(720-33172-11) 2/1/11 14.25 Water X <br /> Pacific �rO <br /> 14:28 <br /> 5725 HALL 2009 INF(720-33172-12) 2/1/11 Pacific Water X D <br /> 13:50 `{ <br /> 802 VERA EFF(720-33172-13) 2/1/11 $ <br /> Pacific Water X <br /> OF <br /> 13:53 Water X Oq <br /> 802 VERA MID(720-33172-14) 2/1/11 Pacific <br /> ' <br /> 802 VERA INF(720-33172-15) 2/1/11 13:56 Water X <br /> P <br /> RC-1 (720-33172-16) 2/1111 13'13 Water X e <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 /> v Deliverable Requested:I, II, III,IV,Other(specify) Special Instructions/QC Requirements: <br /> cQ <br /> (DMethod of Shipment. <br /> Empty Kit Relinquished by: <br /> F. <br /> Time: <br /> pN Relinquishe by D'apte/Tlme: Com�ny RDaterlime:/ Company <br /> o 2-03_ - r <br /> � N Relin � ed by: Datt-!Time:! M f� ComPar � �G Received by: DateRime: Company <br /> ,�1 <br /> Relinquished by <br /> . y�ate/Time: Company Received by: Date/Time: Com <br /> 02-031 125 . a <br /> Custody Seals Intact: Custody Seal No.: Cooler Temperatures)°C and Other Remarks: <br /> A Yes o No <br />