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CHAIN OF CUSTODY 1 LABORATORY ANALYSIS REQUEST FORM <br /> $ 1433 North Market Boulevard,Sacramento,CA 95834 Service Request Na: 5?80,3G73 Purchase Order: <br /> Emcon (91 6)928-3300 FAX(916)928-3341 <br /> Lab: Columbia Anal tical <br /> Project Name:USA Gasoline Station#55,Lodi,Ca Anal sis R uested <br /> Project Number: 20A41-008.001 <br /> Project Manager: Gowri Kowtha W <br /> Company: EMCON-Pinnacle <br /> Address: 144"A" Mayhew Way c W <br /> Walnut Creek,Ca 94596 U <br /> Phone: (925)977-9023 0 o <br /> FAX: (925)977-9030, ( 1 n t <br /> Sampler's Signature: x o <br /> z °° V p REMARKS <br /> Sample LAB ample 1 Container Types <br /> I.D. Date Time I.D. Matrix HCl Preservations <br /> MW-1 E Z5 4 t33? j water 3 3 <br /> MW-3 [Z Z� IZ51 water 3 3 <br /> MW-4 water 3 3 <br /> MW-5 till water 3 3 <br /> MW-6 3 water 3 3 <br /> MW-7 1 l uZ water 3 3 <br /> MW-8 U L water 3 3 <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I. Routine Report <br /> S <br /> ' Signature / Signature Signature 24 hr 48 It, X to day II. Report(includes DUP,MS <br /> LI 6�yt CY Standard(--10-15 working days) MSD,as required,may be <br /> Printed Name PrintedKac Printed Name Printed Name Provide Verbal rnas samples) <br /> tunmary Results di-gea <br /> 5 C/!S Provide FAX Pmlimivary Results III.Data Validation Report <br /> Firm Firm 1 Firrru Firm Requested Report Dau: (includes All Raw Data) <br /> w Z 13011 RWQC3 <br /> DatefrL </.' Q Date r me Datef rime Date/Time (MDLs/PQLs/1 RACE#) <br /> REI. Q ISHED RECEIVED BY Special Instructions/Comments: Container Types Key: <br /> DV , 1 t l Ca Columbia Analytical 40 ml VOA: 1 <br /> Signature Signature V 3 1 i 3334 Victor Court 250 ml LPE: 2 <br /> Santa Clara,Ca 500 ml LPE: 3 <br /> rsrld Name Printed Name 408-748-9700 1 liter HDPE: 4 <br /> Bemadene Cox 500 ml glass: 5 <br /> Firm Firm I liter glass: 6 <br /> Ss ring: 7 <br /> Dateffime Datefrime <br />