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:7--v 4(go <br /> ARCADIS CHAIN OF CUSTODY & LABORATORY Lab Work Order# <br /> Infrastructure.environment,buildings ANALYSIS REQUEST FORM Page—of_ <br /> Contact&Company Name: ,�-�(�� Telephone: _ <br /> $Pyr-}- C' _ , k. E Keys <br /> t✓ Filtered(v) Preservation Key: Container Information Key: <br /> Address: Fax: A. HZSO. 1. 40 ml Vial <br /> U) �¢+Ci L.,, f{Zy�. �,,, #of Contalnere t B. HCL 2. 1 L Amber <br /> F"{ \ 3. 250 ml Plastic <br /> C. HNO <br /> Container a <br /> D. NaOH 4. 500 ml Plastic <br /> C Ciry State Zip E-mail Address: tnformatlon E. None 5. Encore <br /> r9i �S V ���� ,1t1 w�-5:E..i S��- PARAMETER ANALYSIS $t M TROD F. Other: 6. 2 oz.Glass <br /> G.Other: 4 oz.Glass <br /> C-L'�"'\ 8. 8 oz.Glass <br /> Project Name/Location(City,State): Project#: � �'t � 9. Other: L V',I� <br /> H.Other: - <br /> Srynper's Printed Name: �� '_ •r. !/1 <br /> Mlers.5 " t0.01her. <br /> Matrix Key: <br /> SO-Soil SE-Sediment NL-NAPL/Oil <br /> f W-Water SL-Sludge SW-Sample Wipe <br /> Sample ID _ 7 T-Tissue A-Air other: <br /> Matrix dab , REMARKS <br /> vvrt>ow n, / ' \A/ <br /> 9twe,r- Ac'no s' t 13*5 vJ ✓ ✓ ,! �/ t <br /> 1Z�Jet- r3� ✓ v✓ 1/ � <br /> r Ali.rvs 5 1 ost D ✓ ✓ <br /> fZi ve,,r At-res.s D rbi ffo V <br /> ('v`fa- S 4- i 11txx ✓ V,/ rA <br /> ✓ <br /> k2-'Veer A ,S 5 1 ' i i 13c)H_ <br /> ✓ i/ ,/ 1/ <br /> �i 4 t/i�1 Pa ✓' ✓ ✓ ✓ �/ <br /> Special Instructions/Comments: ❑Special QA/QC Instructions(✓): <br /> Laboratory Information and Receipt Relinquished By Received BRelinquished-By Laboratory Received By <br /> Lab Name: y <br /> Cooler Custody Seal ✓) Pnnted Name <br /> Printed Nam P,,,,riName: <br /> Quin <br /> ted <br /> ` r `i i `"�, <br /> tetl Name: <br /> MW-tL ''K"i� �C� ,�.j �•Fi.�f,2 �,`Tw"_ <br /> Cooler Packed with ice(✓) ❑ Intact ❑ Not Intact azure: Si� Si Signature: <br /> Specify Turnaround Requirements: Sample Receipt: Fir um/Courier Firm/Courier: Firm: <br /> 1 S � >'V � <br /> ( lJ <br /> snipping Tracking#: Condition/Cooler Tem Dale .me Dale ime' <br /> Temp: Date/T e: Date/Time: <br /> c'l k1 t�3"� r i�T is !°.?:, 1�l 9 I t� t S�.0j <br /> 0 J � C <br /> 20770826 CofC AR Form 01.12.2007 Distribution: WHITE—Laboratory returns with results YELLOW--Lab copy PINK—Re•lailne;:by A <br />