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esti meri'0ca <br />ANALYTICAL TESTING CORPORATION <br />.:.oC <br />CHAIN OF CUSTODY <br />❑ 885 Jarvis Drive • Morgan Hill, CA 95037 • (408) 776-9600 • FAX (408) 782-6308 <br />❑ 819 Striker Ave., Suite 8 . Sacramento, CA 95834 . !9161 921-9600 . FAX (91Rt WI-ninn <br />Company Name: Q,>;, <br />Mailing Address: <br />MANUwiunT: <br />❑ SDWA (Drinking Water) <br />❑ CWA (Waste Water) <br />❑ RCRA (Hazardous Waste) <br />❑ Other <br />Project <br />Billing Address if dlfferent ; <br />City: <br />State: Zip Code: <br />Telephone; 00f 17 <br />Report To: <br />4Z „S Fax #: �� t <br />E -Mail Address: _ <br />P.O. #: <br />QC -Data _ --Ut.eve14(standard) — Qtevet ift Cr-LeveTIV <br />Sampler: <br />Date/Time Results Required: <br />Test America Work Order # Q <br />iumarouna U 10-15 working Days U 72 hours <br />Time: (Standard TAT) ❑ 48 hours <br />❑ 7 Working Days ❑ 24 hours <br />❑ 5 Working Days ❑ 2-8 hours <br />MANUwiunT: <br />❑ SDWA (Drinking Water) <br />❑ CWA (Waste Water) <br />❑ RCRA (Hazardous Waste) <br />❑ Other <br />ANALYSES <br />REQUESTED <br />Please <br />provide <br />method <br />Comments/Temp. <br />(if required) <br />Q1 <br />� <br />` <br />��1},p <br />Client <br />Sample I.D. <br />Date / Time <br />Sampled <br />Matrix <br />Desc. <br /># of <br />Cont. <br />Container <br />Type <br />Test America's <br />Sample # <br />1 o <br />D l0` <br />+ <br />UI <br />2.: Lt -0 <br />o8 a <br />c r <br />l9 <br />A.<S <br />3. <br />4, <br />5. <br />6. <br />7. <br />8. <br />9. <br />10. <br />A n <br />Relinquished by/Co Received by/Co.: t/ Date/Time/Temp: <br />Relinquished by/ Received by/Co.: Date/Time/Temp: fSsV` <br />eiinquished by/Co.: Received by/Co.: Date/Time/Temp: <br />`Were Samples Received in Good Condition? 'i Yes ❑ No Samples on Ice? C�Yes ❑ No Method of Shipment: Page k of <br />Ite: By relinquishing samples to Test America, client agrees to pay for the services requested on this chain of custody form and any additional analyses performed on this project. <br />Iment for services Is due within 30 days from the date of the Invoice. Sample(s) will be disposed of after 30 days. <br />White: Test America Yellow: Test America Pink: Client <br />