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® w w ® ww ww w w w ® w ® w w <br /> Rev. 1/99 <br /> CHAIN OF CUSTODY/ LABORATORY ANALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 P.O.: <br /> EllltOtl 916 928-3300 FAX 916 928-3341 Lab: <br /> Project Name: Analysis Re uesled <br /> Project Number: 124 <br /> Project Manager: c <br /> Company: EMCON <br /> Address: 1433 North Market Boulevard <br /> Sacramento,CA 95834 0 <br /> Phone: (916)928-3300 iu <br /> FAX: (916)928-3341 E <br /> Sam Icr's Si natur . z REMARKS <br /> Sample LAB Sample >< ConwinerTypes <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_4a tw 5 day 11. Report(includes DUP,MS <br /> Stmadard(-10. working <br /> 15 day,) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Printed Name Provide Verbal PreliminaryResults charged as samples) <br /> Provide FAX Preliminary Results 111.Data Validation Report <br /> Firm Firm Firm Firm Requested Repon Date: (includes All Raw Data) <br /> RWQCB <br /> Date/Time Date/rime Date/Time Date/Time (MDLs/PQLs/I'RACEH) <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 LPG: 3 <br /> Printed Name Printed Name 1 liter HDPE: 4 <br /> 500 ml glass: 5 <br /> Finn Finn 1 liter glass: 6 <br /> 2x6 s/s ring: 7 <br /> Date/Time Date/time glass jar: 8 <br /> FIGURE <br /> CON CHAIN OF CUSTODY DOCUMENTATION - <br />