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• <br /> 720 Olive Drive,Suite D <br /> .�� Davis,CA 95616 <br /> Lab 530 297 4800 l G` <br /> ANALYTICAL ecc Fax 530 297 4803 Lab No / L V Page 3 of 3 <br /> Project Manager Phone No <br /> Tt Rt-Aa e, (516) IS 4-115 a Chain-of-Custody Record and Analysis Request <br /> Company/Address FAX No F For Lab <br /> Kq m $ �h-q f ra k toKekf k l (916 35It - 11ec Analysis Request Use Only <br /> Project Number PO No Project Name e o o W E T (x) Y <br /> C4 C4 <br /> Project Location Sampler Signature o TOTAL(x) N <br /> 342 S. cf th eca. W00 co <br /> a, Lno <br /> container Method o 2 0 0 0 i A <br /> Sampling (Type/Amount) Preserved Matrix H g o (L iL t � z <br /> p a " m m Nr <br /> � v m N 0 Q7 N t- <br /> Q' <br /> Sample € � 6 � _ o z _ _ °° � � � <br /> Designation o -' v z v O ¢ a a 0 0 0 0 1 a <br /> g Rate Time �r m X ar z 3 m m r u� �n ti w w °� 0 <br /> 5a 5 -2S g i9 99 1665 I X S X X <br /> 6139 — 30 ?( S X x x — Z Z- <br /> d S5 - 3s x <br /> se S - Cry too X X w X <br /> I F <br /> Relinquished by Data Time Received by �j,a —7 9 Remarks <br /> QQ <br /> Relin uished by Date Time Received by Email address <br /> ❑ doc ❑ xis ❑ txt ❑other <br /> Relinquished by Date Time Received by Laboratory Bill to R-0411 a �gYt+'oh Wtth� <br /> Disinbutron White-Lab Yellow-File,Rnk-Onginefor V COC fh8(e/98) <br />