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,u 41803 <br /> 0 ARCADIS 1D#: CHAIN OF CUSTODY & LABORATORY Lab Work Order# <br /> Infrastructure,environment,buildings ANALYSIS REQUEST FORM Page_of_ <br /> Contact 8 Company Name: j�Q� Telephone: Preservanvs Keys <br /> p ' '�"��, �/7�, -/y��� t- A Preservation Key: Container Information Key: <br /> .+ wt vw5 FiHered f✓) <br /> A. H2SO4 1. 40ml Vial <br /> Address: Fax: B. HCl 2. 1 LAmber <br /> I �C33C-_ l � c � sof contatnen i C.HNO <br /> G , 3. 250 ml Plastic <br /> aa�+ carnafrwr �- D. NaOH 4. 500 ml Plastic <br /> Information E. None - 5. Encore <br /> F.ity State Zip E-mail Address: PARAMETER ANALYSIS & METHOD <br /> is �� /��-f A6VhL S �i�l� f. Other. 6. 2 oz.Glass <br /> s 7. 4 oz.Glass <br /> CA 7 J 11 Gt rC6 t f—(,5« lyt, (,) G.Other. S 8 oz.Gias <br /> Project Name/Location(City,State): Project#: ,�' T H. Other .� 9 Other:7�' <br /> rzcczb G-M% ,oa �, -"/1_ 10.Other: <br /> Sampler's Printed Name: Sampler's Signature: r� ;! Matrix Key: <br /> ti'1' �l SO-Soil SE-Sediment NL-NAPLIOil <br /> / # W-Water SL-Sludge SW-Sample Wipe <br /> Sample ID ��`lectic TyPet�) <br /> T-Tissue A-Air Other: <br /> p Matrix REMARKS <br /> Date Time Comp Grab <br /> VV Vo" <br /> I-VB 133C VV �✓ ✓ ✓ <br /> r <br /> f <br /> - f <br /> Special Instructions/Comments: ❑Special QA/QC Instructions(✓): <br /> Laboratory Information and Receipt Relinquished By Received By Relinquished By Laboratory Received By <br /> Lab Name: Cooler Custody Seal Printed Name Prmted Name; f 1 Printed Name: rintzitiame: <br /> Cooler packed with ice(✓) 11 Intact C1 Not Intact ure: Signat � Si <br /> Specify Turnaround Requirements: Firm Firm/ FirMCouder: Firm: <br /> Sample Receipt: ,�,l 3 c .9— ` <br /> Z4.3`f1 l 3 'G' ( �� <br /> Shipping Tracking#: Condition/Cooler Temp: Date e: — Dater a: Datem e. oateT e: <br /> a :3.3 ti (( (3' 3S <br /> 20730826 CofC AR Form 01.12.2007 Distribution: WHITE—Laboratory returns with results YELLOW—Lab copy PINK—Retained"b A ADIS <br /> �d0 1 <br />