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CHAIN OF CUSTODY 1 LABORATOO ANALYSIS REQUEST FORM i <br /> 19North Market Boulevard,Sacramento,CA 95834 Service Request No Purchase Order Risk Mn t S] 888-234-7475 <br /> g { ) <br /> >EMCOl1 (916)928-3300 FAX (916)928-3341 Lab SEQUOIA <br /> Project Name IBC-Stockton Anal sis Requested <br /> Project Number 22605-101,001 <br /> Project Manager Deanna Santos N 0 <br /> Company EMCON-Pinnacle c 00 <br /> rn u <br /> Address 1433 North Market Boulevard o <br /> Sacramento,CA 95 ° ovo 0 <br /> Phone (916)928-3300 c 0 o y $ <br /> FAX (916)928-3341 <br /> Sampler's Signature m <br /> z O w REMARKS <br /> Sample LAB Sample k;E 1 I ContynerTypes <br /> ID ate Time ID Matrix " HCI HCI Preservations <br /> MW-I water 5 3 2 ` <br /> MW-2 water 5 3 2 <br /> RE N I D BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> Si natu Signature Signature Signature =aREQUIRE <br /> REQUIREMENTS sda X I Routine Report <br /> 1 y li Report(includes DUP.MS <br /> X Standani(-ILL l5 w.,kang days) MSD as required maybe <br /> nt d Nam Printed Name Pnnted Nam Printed Name Pruvtdo Verbal PrOminrty Results charged as samples) <br /> M 1" <br /> Provide FAX PreLmmary Results III Data Validation Report <br /> z Z Firm Firm Fran Requested Report Date (includes All Raw Data) <br /> T r RWQCB <br /> Dalettime Date/rime Datefrime JDatdTime (MDLs/PQLs/rRACE#) <br /> RELINQUISHED BY LVED BY Special Instructions/Comments Container Types Key <br /> Sequoia Analytical 40 ml VOA 1 <br /> Signature Sign 919 Striker Ave,Ste 8 250 m1 LPE 2 <br /> Sacto,Ca 95634 500 ml LPE 3 <br /> Printed dyne Printed Name 916-921-9600 1 Iter HDPE 4 <br /> 500 ml glass 5 <br /> Finn Ftnn t (�� 1 liter glass 6 <br /> "i 1 ` 2x6 sts nng 7 <br /> ❑atJI rine IDatUtme glass jar 8 <br /> I <br />