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TestAmerica Pleasanton <br /> 1220 Quarry LaneChain of Custody Record TeStl+4meriCa <br /> Pleasanton, CA 94566 <br /> TNF LFarlER IN rNVIRph NFNTaI 7175TINC: <br /> Phone(925)484-1919 Fax(925)600-3002 -/ <br /> Sampler Lab PMC �)C��F'� COC No <br /> Client Information (Stab Contract Lab) Smith,Micah 3 720-38065.1 <br /> Client Contact Phone E-Mail State of Origin Page <br /> ShlppfnglReceiving micah smith@testamericainacom California Page 1 of 4 <br /> Company Accreditation Required(See na(e) Job# <br /> TestAmerica Laboratories,Inc NELAP-Callforl State Program-California 720-85751-1 <br /> Address Due Date Requested: Preservation Codes: <br /> 17461 Derian Ave, Suite 100, 4/1812018 Analysis Requested A-HCL M-He=ane <br /> city TAT Requested(days): y, 8-NaOH N-None <br /> Irvine C-Zn Acetate 0-AsNa02 <br /> State,Zip iD-Nitric Acid P-Na204S <br /> CA,9 261 4-581 7 o E-NaHSO4 0-Na2903 <br /> F ` F,MeOH R-Na2S203 <br /> Phone PO# 6 <br /> 949-261-1022 Tel 949-260-3297(Fax) G-Amchlor 5-H2SO4 <br /> v <br /> { ) O a H-Asrorbic Acid T-TSP Doderahydrate <br /> Email W O# Y I-Ice 11-Acetone <br /> J-Dl Water V-NCAA <br /> K-EDTA W•pH 4-5 <br /> Protect Name Prefect# s <br /> Nestle-Ripon 72000256 L-EDA Z-other(specify) <br /> Site SSOW# Other: <br /> m <br /> Sample Matrix E <br /> Type (wn..mr, , <br /> YPe 8—m, W' Ilp <br /> Sample (CntcmP, owawa an. 31 $ <br /> Sam Ie identifleation•Client ID Lab ID Sample Date Time Gmgrab) ar rir.ae,wnT w m Special InstntctionslNote: <br /> N F?fErserVetitwi Ct�H :' d•, "` a r, <br /> CD 06:50 a. <br /> TB-040518(720-85751-5) 415118 Water X <br /> v Pacific <br /> C MW-5(720-85751-6) 415118 P7:25 Water X 3 <br /> Oo MW-11(720-85751-7) 4/5118 07:44 <br /> Water X 3 <br /> WB-040518(720$5751-8) 4/5118 08:52 Water X 3' <br /> Pacific <br /> M-45A(720-05751-9) 415118 08,58 Water X 3 <br /> M45C(720-85751-10) 415118 09:05 Water X3- <br /> ifi <br /> M-45D(720-85751-11) 415118 09'Pac13 Water X 3, <br /> Paclfi <br /> M-1 6A(720-85751-12) 415118 09'28 Water X <br /> Pacific <br /> M-16C1(720-85751-13) 415118 09.36 Water X 3' <br /> Pacific <br /> Note Since laboratory acereddaWrrs are subfee to change,TestAmenn Laboratories,one places the ownership of method,analyte&accreditation compliance upon out subcontract laboratories Thos sample shipmart4r forwarded under chamotcustcdy if the laboratory does not <br /> currently maintain accreditation or the Slate of Orgm listed above for analysisltestsimatnx being analyzed,the samples must be shipped back to the TestArnw oca fsboratery or❑then enstrucitons wril be provided Any changes to accreditation status should be brought to TestArnenca <br /> Laboratories,Inc attention immediately If ala requested accreditatans are current to date,return the signed Chain of Custody attesting to said complicanoe to TestAmerica Laboratories,Inc <br /> Possible Hazard Identification Sample Disposal(A Jae may be assessed ifsamples are retained longer than 1 month) <br /> Unconfirmed 1 1:3 Return To Client Cl Disposal By Lab ©Archive For Months <br /> Deliverable Requested:I,11,iii,IV,Other(specify) Primary Deliverable Rank:2 Speeiai Instructions/QC Requ)rements: <br /> Empty Kit Relinquished by. Date. Time: Method of Shipmern- <br /> Reimquished by Date/Time C a Received by DateMme Company <br /> e <br /> Relingwshed by Datenime Co pa Ne Received by Daterrime Company <br /> Relinquished by' DatelTime Company Received by Da ^ f� Company <br /> N UA' fT/ �!r7111 <br /> OAR <br /> \ Cust y Se 1s Intact: Custody Seaf No.: Cooler Temp t )°c and Olner Remar* <br /> Yes No <br /> O 3 Q <br /> DICK- <br /> Co Ver.09(2012016 <br />