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1-1 1-1 1111 <br /> q90 <br /> A CADIS °#: CNA A'ST�D*ABORATJRV Lab Work Order# o <br /> ANALYSIS REQUEST FORM Page. of� N <br /> a <br /> Contact&Company Name Wephone <br /> Preservative Keys <br /> Filtered(✓i Preservation Key: Container Information Key: <br /> A. HzSO, 1. 40 ml Mal <br /> Address Fax of Containers g. HCL. 2- 1LAmber <br /> Container E D.HNO, 3, 250 m€Plastic <br /> a G.Information sr22�w ",wet D.NaOH 4. 500 mi Plastic <br /> ;. NoState TO Emi[RddressOne 5. Enra <br /> F. ther: 6. 2 oz Glass ANALYSIS aMETHOD <br /> G.Other 7. 4oz.Glass <br /> i�t�� 2 t 'i — i$L3 r C3 iev 8. Boz-Glass <br /> i'roiect NamelLoca?�orr- % H.Other., 9. Other. <br /> ay. <br /> State) Project# ` <br /> v.. 10-Qthsr: <br /> Tar'.Prsnted Name- 3amp1 9 J <br /> at---� � 2 L 1W//REMARKS <br /> Matrix Key; <br /> t task C,.e✓� �� (� f SO-Sail SE-Sediment NL-NAPLIOil <br /> arW-Water SL-Sludge SW-Sample Wipe <br /> Collection Type{+/) o �y� T-Tissue A-Air Other: <br /> Sample ID matrixDate Time Camp Grab �r tri <br /> Cl4 `�}y#► ! � P y m < T 14 7 <br /> s 1 , -LA 4/-,//13 19401 y5 vs V GO <br /> 1 <br /> 0 <br /> —?Ir� r? j 720-49011 Chain of Custody <br /> - -3 t 41`71)3 1V SO <br /> Spacial Instructions/Co mments: <br /> _ 05pecial RAIGIC Instructions(-/): <br /> Laboratory Information and Receipt Relinquished By Received By Relinquished By Laborotory Received Sy <br /> Lab Name Cooler Custody Seal Primed Name Pd Name .. - Pnnted Name 4 Pentad Name <br /> ���',v, �[����L-"" � LCL �'es.. � � � ifs:✓ L���`�{,• <br /> ❑ Cooler packed with ice(✓) D Intact' Q Not Intact signatuae at s: atu sgnature: <br /> Speafy Tumaround Requxemems- Sample Receipt' Finn: FrtmfCounor FrtmlCou ar Fmn <br /> Shipping 7racung /-I1�CA DT- Urs 95 1- � �-7 <br /> # Condit€on/Cooler Temp: - oate me fE , o —el cat mme V6�� daterrme: j _ <br /> 2073OB26 CoM AR form 01.12.2067 Distribution: WHITE—Laboratory returns with results YELLOW—Lab copy PINK—Retained by ARCADI5 <br />