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r 4 1 <br /> -Vit-vin trr LUSWDY / LABOISORY ANALYSIS REQUEST FORM W <br /> 1433 North Market Boulevard,Sacramento,CA 95834 Service Request No Purchase Order Risk Mngt PO#S4333-0 <br /> EM (916)928-3300 FAX (916) 928-3341_ Lab SEQUOIA <br /> Project Name IBC-Stockton Analysis Requested <br /> Project Number 22605-101.003 <br /> Project Manager Mark Capps <br /> Company EMCON-Pinnacle 00 <br /> Address 3939 Cambridge Road,Suite 220 <br /> 0 <br /> Cameron Park,CA 9682 0 <br /> Phone (530)676-6881 0 o <br /> FAX (530)676-6885 <br /> Sampler's Signature <br /> � REMARKS <br /> Sample Sample .1 t Container Types <br /> D Date Time 1 D Matrix z HCI Preservations <br /> MW-1 3h Fq 11/1 water 3 <br /> MW-2 1l3F water ► 3 � . <br /> t <br /> RFLINQ D BY RECEIVED til' RELINQUISUED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I Routine Report <br /> gnatureig lurc 3tgnature Signature 24 hr as tis 5 day It Report(tnetudes DIJP,MS <br /> its G� f� b X Standard(-10.15 worlangdays) MSD,as required,may be <br /> FruitedHage Printed Name Printed Nance Printed Name Provide Vuba(Prelrmtinary Results charged as samples) <br /> ✓_T� Provide FAX Pr61ninary Results III Data Validation Report <br /> Firm i firm Firm Firm Requested Report Date (mcludes All Raw Data) <br /> ZS 1zh I4 � RWQCB <br /> Mitefrlme Dale/Time Date/tlmc loatelfirne (MDLs/PQLs/TRACEH) <br /> RUINQUISHED BY RECEIVED BY Special Insiructions/Comments Container Types Key <br /> Sequoia Analytical 40 ml VOA I <br /> Stgnatnre Signature 819 Striker Ave,Ste 8 250 ml LPE 2 <br /> Saeto,Ci 95834 500 ml LPE 3 <br /> Printed Name Pnnied Name 916-921-9600 r I liter HDPE 4 <br /> Atin Ron Bobel 500 ml grass 5 <br /> drill Firm l liter glass 6 <br /> 2x6 sls ring 7 <br /> DateiTime Date/rime glass Jar $ <br />