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® rr �■r r� r �r r rr r ® r r ® ® r <br /> Rev. 1/99 <br /> CHAIN OF CUSTODY/ LABORATORY ALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 P.O.: <br /> ElIlt011 (916)928-3300 FAX 916 928-3341 Lab: <br /> Project Name: Analysis Recluested <br /> Project Number: 12 <br /> Project Manager: c <br /> Company: EMCON <br /> Address: 1433 North Market Boulevard <br /> Sacramento,CA 95834 0 <br /> Phone: (916)928-3300 Q) <br /> FAX: (916)928-3341 E <br /> Sam ler's Signat z REMARKS <br /> Sample LAB Sample I I lContainer Types <br /> I.D. Date Time I.D. Matrix Preservations <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X 1. Routine Report <br /> Signature Signature Signature Signature 24 hr 48 hr 5 day II. Report(includes DUP,MS <br /> Standard(-10.15;.acing days) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Printed Name Provide Verbal Preliminary Results charged as samples) <br /> Provide FAX Preliminary Results III.Data Validation Report <br /> Firm Firm Firm Firm Requested Report Date: (includes All Raw Data) <br /> RWQCB <br /> Date/Time Date/Time Date/Time Date/Time (MDLs/PQLs/TRACE#) <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments: Container Types Key: <br /> 40 ml VOA: 1 <br /> Signature Signature 250 ml LPE: 2 <br /> 500 ml LPE: 3 <br /> Printed Name Printed Name I liter HDPE: 4 <br /> 500 ml glass: 5 <br /> Firm Firm 1 liter glass: 6 <br /> 2x6 s/s ring: 7 <br /> Date/Time Date/Time I glass jar: 8 <br /> FIGURE <br /> MCO CHAIN OF CUSTODY DOCUMENTATION ®3 <br />