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CHAIN OF CUSTODY 1 LABOROORY ANALYSIS REQUEST FORM i <br /> 1433 North Market Boulevard,Sacramento,CA 95834 Service Request No Purchase Order <br /> 1Emcon (916)928-3300 FAX(916)928-3341 Lab SEQUOIA <br /> Project Name IBC-Stockton Analysts Requested <br /> Project Number IT#792754 122605-101 003 <br /> t <br /> Project Manager Mark Capps o <br /> Company IT I EMCON <br /> Address 3939 Cambridge Road,Suite 220 ca n <br /> Cameron Park,CA 9682 0 <br /> Phone (530)676-6881 w >C N <br /> FAX (530)676-6885 ° <br /> Sampler's Signature � A <br /> z H REMARKS <br /> Sample LAB Sample 1 Container Types <br /> ID Date Time ID Matrix C- HCI Preservations <br /> MW-1 to I Z water 3 3 <br /> MW-2 /r water 3 3 <br /> RELINQUISH Y RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I Routine Report <br /> S lure Signa ury ignature Signature 24 hr 48 hr Sday 11 Report(includes DUP,MS <br /> X Standard(-11}15 WDrkag days) MSD,as required,may be <br /> Panted Mame Prin d Name U Printed Name Printed Name Prowde Verbal Preliminary Results charged as samples) <br /> 1-1 5 c.� ProvtdeFAX Preliminary Results Ili Data Validation Report <br /> FirmFirm Firm Requested Report pate <br /> /p P f /oD FlrmSeaoO i � e� po (includes All Raw Data} <br /> `/ RWQCl3 <br /> DateJrlme Date/T m Daterrime Date/rime (MDLs/PQLs(TRACE#) <br /> RELINQUISHED BY RECEIVEDBY Special Instructions/Comments Container Types Key <br /> Sequoia Analytical 40 ml VOA I <br /> Signature Signature 819 Striker Ave,Ste 8 250 ml LPE 2 <br /> Sacto,Ca 95834 500 ml LPE 3 <br /> Printed Name Printed Name 916-921-9600 1 liter HDPE 4 <br /> J Ann Ron Bobel 500 ml glass r 5 <br /> Firm Firm I liter glass 6 <br /> 2x6 s1s ring 7 <br /> Datelrinle Datelrtme glassjar 8 <br />