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4&sServiceS olumbia CHAIN OF CUSTODY/LABORATORY ANALYSIS REPORT FORM <br /> Analyhcol l ,j? r ) G <br /> 3334 Victor Court•Santa Clara CA 95054 SERVICE REQUEST NO "'- �J ( ` P O PAGE ' OF <br /> "" __ #_ <br /> n r wLL, I I I (40$)74$9700 FAX(40$)74$9$60 <br /> C ANALYSIS REQUESTED <br /> PROJECT NAME_1J r! y� �n__ ______ PRESERVATIVE HCI HCI HCI NP NP NP HCI HNO NP H SO N30H <br /> PROJECT MGR - UI ��v�.�1,i/,�� ------- r, v o <br /> COMPANY—,6 y -= `� 1 Z Vm`C tia u <br /> Q un <br /> ADDRESS—/ L} J ,.� ,�C / i T Z m `�°o o`� y h o o <br /> �J < -7 / r 0 y cv o cb f7 O ni a�°i C 0 Y <br /> PH0N�ly/�b�11 )r roles o` CR. y co <br /> Do a `b n� Uma U O p Rr �l1 <br /> FA7�l4 Cz-3) G� O Lao A v Qr\ �o co aO z O <br /> Ory �� O �m a"iy a � a . 8 k <br /> SAMPLERS SIGNATURE _ `o �o m to <br /> SAMPLE LAB SAMPLE Do a m Qrr Qtr m h m 20.,° °'o rac 2p REMARKS <br /> 1 D DATE TIME ID MATRIX z ,�o Zco ``rm mro <br /> L/ y- rGlo. 13� - ;x <br /> l✓- u2 Ir co / 33G <br /> I <br /> ELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REQUIREMENTS REPORT REQUIREMENTS <br /> I {�l `�A�� _ I Routine Report <br /> �/ 1 day —2 day —3 day II Re 4 includes MS <br /> Si natur Signature r r Signature Signature <br /> _ � 5 day �Other MSD as required maybe <br /> L c �(,h �, _ /� 7 _ — — charged as samples) <br /> anted Name L Printed Name Printed Name Printed Name <br /> LI v✓1 �� Slandard(10 working days) _ III Data Validation Report <br /> i 9 s _ (includes All Raw Data) <br /> Firm Firm - rJ ' r Firm Firm <br /> i �/!� ��7{ ? S�/� / �� nu Results Due _ MDLsIPQLs+Trace s <br /> ateb rhRi a Date/T+me DatelTime Date/Time _ Electronic Data Deliverablesf I <br /> RELINQUISHED BY RECEIVED BY SAMPLE RECEIPT Condition _Custody Seals <br /> 1 SPECIAL INSTRUCTIONSICOMM>=NTSy C"Nejlq j <br /> Signature Signature Circle which metals are to be anal zed ✓ <br /> Printed Name Printed Name Metals AI 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 /> Dateffime DatelTime <br /> Storac, <br /> ped ckm_ ___JMW—= M=— <br />