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CHAIN OF CUSTODY /LABORODRY ANALYSIS REQUEST FORM <br /> QP1433 North Market Boulevard,Sacramento,CA 95834 Service Request NoS[ C10 1 Purchase Order # <br /> aFMC011 (916)928-3300 FAX(916)928-3341 Lab CAS <br /> Project Name IBC-Stockton Anal sis Re uested <br /> Project Number 22605-100.001 .� <br /> Project Manager Claudio Avila c�•t <br /> Company EMCON00 <br /> Address 1433 North Market Boulevard <br /> 0 <br /> Sacramento,CA 95834 U 00 <br /> Phone (916)928-3300 0 >C <br /> FAX (916)928-3341 �. <br /> Sampler's Signature <br /> � x <br /> z � REMARKS <br /> Sample LAB Sample 1 Container Types <br /> I D Date Time I D Matrix HCI Preservations <br /> MW-1 rj -) ic,q 1 2 2 <br /> MW-2 102— 2. 2 2 <br /> Rjs#.I HED BY REC IVSD B( r RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I Roulmi,Report <br /> Signaturesignat f/ Signature Signature 24h 48 hr 5day II Report(includes DUP MS <br /> r7t)6, X Standard(-til 15 working days) MSD as rLquired may be <br /> Printed Nam Printed Narne Printed NamE. Pnnted Name Provide Verbal Preliminary Rcculr% LhargLd.Ls samplt s) <br /> C)w T C- I S <br /> Yruvide FAX Prehmmary RL.u1L% III Data V-Iidahon RLport <br /> Finn Finn Firm Finn RcyutStrd Rclxxl Date (intlu&s,All Raw Data) <br /> -77 cl 1 )j RWQCB <br /> DatLfrirue Date/Tune Datef ime DateMme (MDLs1PQL,/ RACE#) <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments Container TypLs KLy <br /> 40 nil VOA <br /> 5rgnaturL Signature 250 ml LPE 2 <br /> 500 inl LPE I <br /> Printed Narne Printed Name 1 )tier HDPE 4 <br /> 500 mi glass 5 <br /> Firin Firm 1 liter glass 6 <br /> � 2x6 sls ring 7 <br /> Date/Time DatelTtme glass lar 8 <br />