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I eSTHmeri ca lrvine Chain of Custody Record TestAmedca <br /> 17461 Derian Ave 057794 <br /> Suite 100 <br /> THE LEADER IN ENVIRONMENTAL TESTING <br /> Irvine, CA 92614 TestAmerica Laboratories, Inc. <br /> Phone: 949.261-1022 Fax= Regulatory Program: ❑DW ❑NPDES ❑RCRA ❑Other: TAL-8210I0I19) <br /> Clienj C ntact Project Manager: Site Contact: Date: COC No: <br /> Company Name: Tel/Fax: Lab Contact: Carrier: of COCS <br /> Address: �] Analysis Turnaround Time Sampler: <br /> Cityl5tateop: M U ❑ CALENDAR DAYS ❑ WORKING DAYS For Lab Use Only: <br /> Phone: TAT if different from E0v+ Z Walk-in Client: <br /> Lab Sampling: <br /> Fax: El z w <br /> Project Name -; f 4.=I ' ❑ t xr8k ' } <br /> Site: El2 day, ; " Job!SDG No.: <br /> PO# ❑ I[L1y e y V <br /> Sample .� <br /> Type <br /> t <br /> Sample Sample m o <br /> P P C=ComcOmp #of y <br /> Sample Identification Pate Time G=Grab) Matrix Cont. (Le Sample Specific Notes: <br /> Preservation Used. 1=Ice, 2=HCl-' 3=HZS04+ 4=HNO3; 5=NaOH;6=Other <br /> Possible Hazard Identification' Sample Disposal(A fee may be assessed if samples are retained longer than 1 month) <br /> Are any samples from a listed EPA Hazardous Waste? Please List any EPA Waste Codes for the sample in the <br /> Comments Section if the lab is to dispose of the sample. <br /> ❑Non-Hazard ❑Flammable _I Skin Irritant ❑Poison B ❑Unknown ❑Return to Client ❑Disposal by Lab ❑Archive For Months <br /> Special Instructions/QC Requirements&Comments: <br /> Custody Seals Intact: ❑ Yes ❑ No Custody Seal No.: Cooler Temp.( ):0 bs'd: Cored: Therm rD No.: <br /> Relinquished by: Company- Dat I Receive� � Company:. Dalelfine: <br /> / �� t {� 1 �T � <br /> Relinquished by: Company: Date Ime. Received by: company, 17ate1Time; <br /> c 3 f 1 1 <br /> Relinquished by: Company: Date!Time: Received in Laboratory by: Cumyiany: Date/Time: <br />