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TestAmerica Pleasanton jJ111 1�1� TestAmerica <br /> 12200uarryLane Chain of Custody Record inl <br /> onsmommommom <br /> Pleasanton, CA 94566 <br /> -Or Lr49r9 EM fN VSA0 NMF4T nt'ra TlNr, <br /> Phone(925)484-1919 Fax(925)600-3002 <br /> Sampler. Lab PM' CarsierTrackmg No(s). COC No, <br /> Client lntornlation (Sub CorttraCt Labs Smith,Micah 720.38018.1 <br /> Client Contact Phone- E-Mad• State of Origin, Page* <br /> ShlppinglRecerving rnicah.smith@testamericainacom California Page 1 of 1 <br /> Company. Atcreditabona Required(See oote). Job#. <br /> Testikmerica Laboratories,Inc NELAP-Cal-domia;State Program-California 720-85751-1 <br /> Address. Due Date Requested: Preservation Codes: <br /> 17461 Derian Ave, Suite 100, 4/18/2018 Analysis Requested A-HCL M-Hexane <br /> Cay, TAT Requested(days), 6•NaGH N-None <br /> lrvl7se C-Zn Acetate O-AsNa02 <br /> State,Zip- 'i D-NfMc ACA P-Na204S <br /> CA.92614-5817 -NaH504 0-Ne2so3 <br /> Phone. PO#. y F McOH R-Na2S203 <br /> G-Amchrm S-H2SO4 <br /> 949-261-1022(Tel) 949-260-3297(F'ax) "g _A H-Ascorbic Acid 7-TSP Dodecehydrate <br /> Email. WO# Z I-ice U-Acetone <br /> 7ti' s J-DI Water V-MCAA <br /> K-EDTA W-pH 4.5 <br /> Project Name- Prefect#. 31 ' L-EDA Z-other(specdy) <br /> Nestle-Ripon 72000256 0 <br /> Site. $SOW# a other: <br /> N 1�' <br /> b <br /> Sample Metrix z <br /> Type <br /> Sample (CRcomp, o.--. ,t, 141 <br /> � Sam fe{derttlfication-Client 1B Lab 1D Sample pate Time G-grab) BT-ra.°.,A.ur � Special Instructions/Note: <br /> N PiOFVgltofj' <br /> LL <br /> T&040518 720-85751-1 41511 " <br /> , <br /> �D ( ) 8 06:50 WaterX �2� <br /> v P fic <br /> O MW-3(720-85751-2) 415118 07'08 Water X 3` <br /> CO MW-7(720-85751-3) 415/18 W1_7 Water X �1 <br /> Pa tfi <br /> MW-10(720-857514) 415118 Pa Water X 3. <br /> Pacific <br /> E <br /> ;•. ; <br /> Note Since laboratory accreditation are subject to change,TestAmenCa Laboratones,Inc,ptaces the ownership of method,analyte 8 accreditation compliance upon out subcontract 3aboratories This sample shipment is forwarded under chambf-custody If the laboratory does not <br /> currently maintain actreditabon in the State of Origin listed above for analysishestslmatns being analyzed,the samples must be shipped back to the TeS64meflca laboratory or other instructions wdI be provided. Any charges to acoreddabon status should be brought to TestAmenca <br /> Laboratones,Inc attention immediately If all requested accreditation$are current to datet return the signed Chain of Custody attesting to said complicance to TestAmenca Laboratories,Inc. <br /> possible Hazard Identification Sample Disposal(A fee may be assessed ff samples are retained longer than 1 month) <br /> Unconfirmed 0 Retum To Client 0 Disposal By Lab Archive For Months <br /> Deliverable Requested:1.It,III,IV,Other(specify) Primary Deliverable Rank.2 Special Instructions/M Requirements: <br /> Empty Kit Relinquished by: IDate: Time: Method or shipment <br /> Reirnquished by. Daterri a ny Received by Darterrime Company <br /> (icq I Aid Q2 <br /> Relinquished by DatelTi e. y Received by DatelTime, Company <br /> €j Rellncl.shed by Date/Time Company Received try DatelTi Company <br /> O '17 <br /> CD Custody Seats Intact: Custody Seal No.: Cooler Temperatures)°C and Other Remarks, <br /> O . �_ <br /> A Yes A No <br /> Co Ver 09f20126 6 <br />