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7estAmerica Pleasanton Test>r4rnerica <br /> 1220 Quarry Lane Chain of Custody Record <br /> Pleasanton, CA 94566 <br /> TNF LFhOFp fk F4blprYklJF kTht irSTikC <br /> Phone(925)484-1919 Fax(925)600-3002 <br /> Sampler Lab PM Carrier Tracking Nc(s COC No <br /> Client information (Sub Contract Lab) Smith,Micah f 720-38065.2 <br /> Client contact Phone E-Mall to o(7ngin Page, <br /> ShippinglReceitnng micah.smithatestamericainc.com Califamia Page 2 of 4 <br /> Company Accreditat,ons Required(See notal Jot,#• <br /> TestAmerica Laboratodes,Inc NFLAP-California;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 /> City TAT Requested(daysi: a, B-NaOH N-None <br /> t ntwe C-Zn Acetate O-AsNa02 <br /> State,Zip <br /> D-Whir Acid P-N.2045 <br /> CA,92614-5817 E-NaHSO4 Q-Na2SO3 <br /> Phone PO# F-WOH R-Na2S203 <br /> 949-261-1022(Tel) 949-260-3297(Fax) G-Amchlor 5-H2SO4 <br /> U <br /> p m H-Ascorbic Arad T-TSP 9odecahy dials <br /> Email Vila f+ Z I-Ice t1-Acetone <br /> J-Dl Water V-MCRA <br /> rd° K-EDTA W-pH 4.5 <br /> Protect Name Protect# L-EDA Z-other{speedy) <br /> Nestle-Ripon 72000256 is <br /> Site SSOW# 0 ONrer: <br /> Sample Matrix <br /> Type (w-w.r.r 31 ; <br /> Sample (C=comp, oas...moa, o <br /> Sample Identification-Client ID Lab ID Sample Date Time Gamabli I, Special Instructions/Note: <br /> N fit s��iVat9orf,Code;'iI. <br /> M-16C1 DUP(72M5751-14) 415118 09:36 Water X 3 <br /> �I P CIfIC <br /> Q M-39C(720-85751-15) 415!18 pa If9 Water X 3 <br /> Pacific <br /> Co M-5A(720.85751-16) 4!5118 P :0c Water X 4J' <br /> M-5C1(720-85751-17) 415118 10.12 Water X 3 <br /> Pacific <br /> 1019 <br /> M-5C2(720-85751-18) 415!18 Pacific Pa rfiWater X 3 <br /> M-36C(720-85751 A 9) 415118 10'43 Water X 3 <br /> Pacific <br /> M-36A(720-85751-20) 4!5118 10.56 Water X 3 <br /> Pacific <br /> M-34C(720-85751-21) 415118 11.04 Water X 3 <br /> Pa ific <br /> M-34D(72M5751-22) 415118 11'13 Water X 3 <br /> Pacific <br /> Note Since laboratnry accreditanons are subject to change,TestAmenra laboratories,Inc places the ownership of method,anafyie 8 accredilabon compliance Upon out subcontract laboratories Thu sample shipment is forwarded under chainofcustody I <br /> Possible Hazard Identification Sample Disposal(R fee may be assessed if samples are retained longer than 1 month) <br /> Unconfirmed =Return To Client ©Disposal By Lab Archive For Months <br /> Deliverable Requested:I,Il,ill,IV,Other(specify) Primary Deliverable Rank.2 Special instructionslQC Requirements: <br /> Empty Kit Relinquished by, Date: Time. Method of Shipment <br /> Relinquished by DAteg;mq eceived by Daieamie company <br /> Relinquished by Daf €me Company Received by DaleRlme Company <br /> N)j Reirrquishad by Daterrime Gompany Received byDatefTi r Co a <br /> _ ETA V <br /> OC tody Se Is Intact- Custody Seal No: Cooler Temperatures)°Can s ! r� <br /> A Yes A No �p v <br /> 00 V Ver:0912012016 <br />