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CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM Page_of_ <br /> Shaw Environmental P.O.No: Direct Bill San Joaquin County <br /> 1326 North Market Boulevard,Sacramento,CA 95834 Lab: CAS,Simi Valley <br /> Project Name:Foothill Landfill,San Joaquin County Analysis Requested <br /> Project Number: 124591(Surface Water) <br /> Report to: Sheila Richgels o <br /> Company: Shaw Environmental <br /> Address: 1326 North Market Boulevard N v <br /> Sacramento,CA 95834 0 °O -0 [ <br /> Dir Ph: 916 565-4327 / FAX: U d a, z w <br /> ( ) (916)Sb5-4356 o W � o � <br /> Sampler's Signature: o q� P; <br /> z > U z REMARKS <br /> Sample LAB Sample vow Liter LPE / 250ml 500Container Types <br /> I.D. Date Time I.D. Matrix HCl NP03 Preservations <br /> S-1 water 6 3 1 Z1 <br /> S-2 water 6 3 1 I <br /> RELINQUISHED BY RECEIVED BY INQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I. Routine Report <br /> Signature Signature Signature Signature 24 hr _48 hr _5 day II. Report(includes DUP,MS <br /> X Standard(-10-15 working 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 /> Finn Firm Firm Firm Requested Report Date: (includes All Raw Data) <br /> X RWQCB <br /> Date/Time Date/Time Datefrime Date/Time (MDLs/PQLs/TRACE#) <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments: Container Types Key: <br /> Columbia Analytical 40 ml VOA: 1 <br /> Signature Signature Please report MDLs,PQLs and Trace. 2655 Park Center Drive,Suite A 250 ml LPE: 2 <br /> Nitrate-Nitrogen has a 48-hr hold time. Simi Valley,CA 93065 500 ml LPE: 3 <br /> Printed Name Printed Name 805-526-7161/Fx 805-526-7270 1 liter HDPE: 4 <br /> Contact: Karen Ryan 500 ml glass: 5 <br /> Firm Firm UPS Acct 9653E1 1 liter glass: 6 <br /> EDDs to<susan.waterman@shawgrp.com> 2x6 s/s ring: 7 <br /> Date/Time Date/Time glass jar: 8 <br />