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❑ F-1 Ll Ll 19 <br /> aw 1 q❑zGz <br /> 0 ARCADISCAIN YMA &ORY Lab Work Order#ID#: o <br /> rzre=rrucr�•e:varve fnvercnmrn.Bu••f.gs ANALYSIS REQUEST FORM Page of N <br /> rn <br /> Contac`&Company Name: ywTefephons: Preservative "t..3 i;L^a.. Keys <br /> /4 <br /> �a s w �G 1�ta C s G� -2�� - ry�,� �a� Fittered Ste} Presematian Key,, Container Information Key: <br /> y t V <br /> A. <br /> Address: Fax <br /> tizSOs 1. 4€I ml Vial <br /> y Ufat� t G �:I Pec ofContatners B. HCL 2. 1I-Amber <br /> C.HNO, 3. 2500Plastic ml Plasilc <br /> Contatner1G•h D.NaOH 4. 500 ml Plastic <br /> tnfarmauan ,rel? E. None 5, Encore <br /> C Cay State ZEp E- MAddre=s. <br /> PARAMETER ANALYSIS&METHOD F. Other. 6. 4oz.Glass <br /> e v�y�F�'tL� 7. 4vz.Glass <br /> L1 to v �$�J,t G.Other. 8. 8 oz.Glass <br /> Protect NamefLoeaf n(ciry.state) Airot #® f tir8. Other. <br /> H.Other <br /> zo_other: <br /> sampler's Pnnted Name. Sample' i not reMatrix Key: <br /> In L k3 vC�C' °� r ,r Z � � <br /> c Z e� w`] t>� ,=� s SD•Swi SE-Sediment NL-NAPLIOtI <br /> s s W-Water SL-Sludge SW_Sample Wipe <br /> Collection Type(✓) 2 v x T-Tissue A-Air Other. <br /> Sample ID Matrix <br /> } <br /> Date Time Comp Grab �{� {REMARKS <br /> So <br /> � 5 -6 - ;,ell 14:(tip Y_ `jC <br /> G yM <br /> co <br /> v3` '/ 1i{3 f�. -X <br /> Li <br /> Special InstructionslComments. t [ <br /> ��� 720-48992 Chain of Cu r� <br /> stods <br /> Laboratory Information and Receipt Relinquished By Received By Tic a,,,, ,_ .sy Laboratory Received By <br /> Lab Name Cooler Custody Seal(✓j Printed Niiame: y� Printed Nam, Pn ted'Name-[ i Pnnted N me <br /> [] Cooler packed with ice(✓i ❑ Intact Q Not Intact Signa or t-� ,,,_, at e• nate e. ���__ _ Signa re x �` <br /> Speafy Turnamuntl Requcrements- Sample Receipt: Fttm Firm <br /> sh[pp3ng Tmck3ng it Condition(Cooler Temp: oateMme. 17 oatemme Pp et e oaEeTimo: <br /> 2073(182♦;CdCAtz Femt 01.122007 Distribution: WHITE—Laboratory returns with results YELLOW—Lab copy PINK—Retained by ARCADiS <br />