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'.,�.7 rte"` r-7r-'7' �..."! �, V" C-7 r". r" r- f r-7 r-7 7 ` r" 177" t"7 r7, <br /> SAMPLE CHAIN-OF-CUSTODY ANALYSIS REQUEST Shasta Analytical Laboratory'l <br /> ! 20280 5kypark Drive • Redding, CA 960M <br /> POSST6LE HA21R05: (530) 226r5400 Fax (530) Z2fr 7T22 <br /> wo rc,k 2 ff 2000 Deport to <br /> ��CrI�T�� r�� ANALYSES REMMS[ED e <br /> Date <br /> Company Chckyleti f WC Itan X 10c Cr.1 �i a <br /> Source of Samples 7-- <br /> sempler Name r-. Address t ' <br /> Company �ti/ r V FU Rkc.t] ] VnaGC (�Dttil el�,nc( s[�f5���� <br /> Phone: <br /> Project Ho. DFTbp1t7 1 Iax: <br /> - C0m1gHTS/coNDiT10NS: <br /> COLLECTION - -- - Turnr }� �` — - container rxlrfstr, etc-) <br /> ICortpo- Nott around (Container type, <br /> LAB f0 No. C:ient t4 No, Date liar hype Deolh site A <br /> 00 <br /> �Jti f �� i t X X Rr,aly�i;lrn�y 13 '1 �15 . Fluid ] 'i�.s t <br /> t � <br /> ' <br /> X r,�-,4, ,l f lolr� l a,v i t �z�'' u � is f-14.s <br /> tit) Sled 2: y, 1ICA.J c Ll Sr, )ISS <br /> a?93/cf9K <br /> 04) <br /> Z <br /> g- -IS i llo4r�2� l5•s <br /> N� �, AlvlyzC01k) 8�2 -20 - yf�l4 2- <br /> 4) Preservation of sMp(e. <br /> 1) 4rite only one Semple nuxber in each space. 5) Write each anelysas requested •erase 1aP. Piece an"11° in <br /> 2') specify type-cf-sanple(s) Water(V), Solid.($), -or_irdicate_type-_ �� a Tale column-to indicate type_of,_ane_l_ysis needed for <br /> 3) Mark each sample which should be cooposited in Laboratory as follows: PLact an A" in box for e�osrrpte. <br /> each sample that should be conposited into one sample; vse sequential tetter for additional groups. <br /> SAMPLE I<ECEIVLO BY: <br /> SA*PLE RELINOl11SHED BY: <br /> Print Name S <br /> ignatureCtxrpany Date 7imne <br /> Print Name Signature eonpany oat time <br /> 1ZICHAkD CAS-16S ` "�te ,!✓�i�f _/vu '+ _Y' <br /> Carrier: n�h 7Jy1w <br />