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olumbia CHAIN OF CUSTODYILABORATO <br /> RY ANALYSIS REPORT FORM <br /> &AS�Analyfical <br /> Semces 3334 Victor Court•Santa Clara,CA 95054 SERVICE REQUES r NO P O# PAGE OF " <br /> Emw Ca.n (408)748 9700•FAX(408)748 9860 <br /> t 4 r ANALYSIS REOUESTED <br /> PROJECT NAME -� t -} # PRESERVATIVE HCI HCI HCI NP NP NP HCI HNO NP HS0, Na0H <br /> co PROJECT MGR ` I 1 �� 1 y r?� <br /> a°i U N o <br /> COMPANY <br /> u <br /> W <br /> mo o m Z�¢ <br /> „ �U <br /> C? o 2 3 <br /> ADDRESS o !�v o cod a �o Lc U Q CO <br /> q y C 4 D <br /> 6f G,',=�F' f I '✓ T? �f PHOy� }% 1� i , m� a-11 <br /> a D Um g o ��` <br /> SAMPLER'S SIGNATURE m �� o ro y �� Z� nam �� `f7 OZ <br /> 2= <br /> a,o m 'uU <br /> SAMPLE LAB SAMPLE Z ZQrQ ,arm�mti Q m�Q� fo� Q 2 O REMARKS <br /> D DATE TIME ID MATRIX co rp ti 2 ro O Q U <br /> .? 1 Jfr� <br /> ( <br /> e <br /> Y'il,f r Ili Ir ' j! i <br /> i1 <br /> 1, 1 f r t� <br /> J <br /> �iELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REQUIREMENTS REPORT REQUIREMENTS <br /> ! a/ J I Routine Report <br /> n <br /> Signature J Signature Signature Signature — i day f 2 day_3 day _ II Report(includes MS <br /> cg T f "h �" or ! MSO asraquired maybe <br /> Panted Name Panted Name Printed Name Printed Name 5 day _Other charged as samples) <br /> Standard(10 working days) III Data Vatidalion Report <br /> ' J -,r Firm Firm <br /> (includes All Raw Data) <br /> FirmFirm, F r 7 - ' , Results Due _ MDLsIPOLsITrace# <br /> Date/Time Date/Time Datell line DatelTime Electronic Data Deliverables <br /> RELINQUISHED BY RECEIVED BY SAMPLE RECEIPT Condition Custody Seals <br /> SPECIAL INSTRUCTIONS/COMMENTS <br /> Signature Signature Circle which metals are to be analyzed r <br /> Printed Name Printed Name Metals Al Sb Ba Be B Cd Ca Cr Co Cu Fe Mg Mn Mo Ni K Ag Na Sn V Zn <br /> As Pb Se TI Hg <br /> Firm Firm <br /> DatefTime DateFTrme <br /> Storag <br /> Shipped viarrWnq# <br /> �_. ,� r+� r�� rl �,„„�,1,,.�4�nfinn�i.fnr aariul�rr•h Ca�lr. ....r � ' <br />