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Rev. 1/99 <br /> 00 CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 P 0 <br /> EIIICOn 91 928-3300 FAX 91 928-3341 Lab: <br /> Project Name: <br /> Project Number: Anal sis Re uested <br /> m <br /> Project Manager: <br /> Company: EMCON <br /> Address: 1433 North Market Boulevard o <br /> v <br /> Sacramento,CA 95834 i <br /> Phone: (916)928-3300 <br /> FAX: (916)928-3341 <br /> Sampler's Signa u.. EREMARKS <br /> Sample LAB Sample : <' <br /> E i Container Types <br /> I.D. Date Time I.D. Matrix :3�< <br /> 0 <br /> Preservations <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> RELINQUISHED BY RECEIVED BY d4ff <br /> RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> Signature REQUIREMENTS X I. Routine Report <br /> €n Signature Signature Signature 24 hr 48 hr 5 day II. Report(includes DUP,MS <br /> X Standard(—lo-ls.vorkingdays) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Printed Name Provide Verbal Preruninar Results charged as samples) <br /> Requested Provide FAX Preliminary Results III.Data Validation Report <br /> Firm Flrm Firm Firm Report Dote: (includes All Raw Data) <br /> Date/TimeRWQCB <br /> DatelTiDateJTime Date/time MDLs/P Ls/TRACE# <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments: Container Types Key: <br /> Y: <br /> Signature Signature 40 ml VOA: 1 <br /> 250 ml LPE: 2 <br /> Printed Name Printed Name 500 ml LPE: 3 <br /> 1 liter HDPE: 4 <br /> Firm Firm 500 ml glass: 5 <br /> 1 liter glass: 6 <br /> Date/Time Date/Time 2x6 s/s ring: 7 <br /> lass'at: 8 <br /> FIGURE <br /> ERACON <br /> owl WATER SAMPLE FIELD DATA SHEET <br />