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rr rr ® ® rr rr rr r <br /> - Rev. 1/99 <br /> CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> 0 1433 North Market Boulevard,Sacramento,CA 95834 P.O.: <br /> ft11000 916 928-3300 FAX 916 928-3341 Lab: <br /> Project Name: Anal sis Re uested <br /> Project Number: 12 <br /> Project Manager: <br /> Company: EMCON c <br /> Address: 1433 North Market Boulevard <br /> Sacramento,CA 95834 0 <br /> Phone: (916)928-3300 <br /> FAX: (916)928-3341 EREMARKS <br /> Sam ler's Si atur . Z <br /> Sample LAB Sample Container Types <br /> P Preservations <br /> I.D. 7D7ate=TimeI.D. Matrix <br /> :0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> RELINQUISHED 13Y RECEIVED BY RELINQUISHED BY RECEIVED 13y TURNAROUND REPORT REQUIREMEN"rS <br /> REQUIREMENTS X 1. Routine Report <br /> Signature Signature Signature Signature 24 hr 4s hr s(lily 11. Report(includes DUP,MS <br /> Stutulurd(-10-13workingduyu) 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/rime Datelrime Date rime Date/Time (MD ontain s/T ypes Ke <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments: Container Types Key: <br /> 40 ml VOA: 1 <br /> 250 ml LPE: 2 <br /> Signature Signature 500 ml LPE: 3 <br /> 1 liter I-IDPE: 4 <br /> Printed Name Printed Name 500 ml glass: 5 <br /> 1 liter glass: 6 <br /> Firm Firm <br /> 2x6 s/s ring: 7 <br /> glass jar: 8 <br /> Date/Firne Date/Time <br /> FIGURE <br /> WATER SAMPLE FIELD DATA SHEET - <br />