Laserfiche WebLink
Rev. 1/99 <br /> CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> 0 1433 North Market Boulevard,Sacramento,CA 95834 P.O.: <br /> >EIIfltOti 91 928-3300 FAX 91 928-3341 Lab: <br /> Project Name: Anal sis Requested <br /> Project Number: y <br /> Project Manager: <br /> Company: EMCON t6 <br /> C <br /> Address: 1433 North Market Boulevard <br /> U <br /> Sacramento,CA 95834 0 <br /> Phone: (916)928-3300 - <br /> FAX: (916)928-3341 E <br /> Sampler's Signatu . z REMARKS <br /> Sample LAB Sample .« Container Types <br /> .:> <br /> I.D. Date Time I.D. Matrix Preservations <br /> 01 1 <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 I. Routine Report <br /> Signature Signature Signature Signature 24 hr — —49 h 5 4 II. Report(includes DUP,MS <br /> tan <br /> Sdard( 5 woring days) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Printed Name Provide Zal Preliminary Results charged as samples) <br /> Provide FAX Preliminary Results III.Data Validation Report <br /> Firm Firm Finn Firm Requested Report Date: (includes All Raw Data) <br /> RWQCB <br /> Date/Time Date/Time Date/Time Date/Time MDLs/P Ls/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 1 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 glassjar: 8 <br /> FIGURE <br /> EMCONWATER SAMPLE FIELD DATA SHEET ®3 <br />