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Rev. 1/99 <br />CHAIN OF CUSTODY / LABORATORY ANALYSIS REQUEST FORM <br />1433 North Market Boulevard, Sacramento, CA 95834 P.O.: <br />gmc®n 916 9Z8-33UU FAX 916 9Z8-3341 <br />Lab: <br />Project Name: <br />Analysis Requested <br />Project Number: <br />rn <br />Project Manager: <br />c <br />Company: EMCON <br />m <br />Address: 1433 North Market Boulevard <br />c <br />0 <br />U <br />Sacramento, CA 95834 <br />0 <br />Phone: (916) 928-3300 <br />- <br />FAX: (916) 928-3341 <br />Sampler's Signature. <br />z' <br />REMARKS <br />Sample LAB Sample <br />Container T es <br />I.D. Date Time I.D. Matrix <br />'> <br />Preservations <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />RELINQUISHED BY <br />RECEIVED BY <br />RELINQUISHED BY RECEIVED BY <br />TURNAROUND <br />REPORT REQUIREMENTS <br />Signature Signature <br />REQUIREMENTS <br />24 hr 4g hr 5 day <br />X I. Routine Report <br />Il. Report (includes DUP, MS <br />Signature <br />Signature <br />Printed Name Printed Name <br />X Standard (-10.15 working days) <br />Provide Verbal Preliminap Results <br />MSD, as required, may be <br />charged as samples) <br />Printed Name <br />Printed Name <br />Firm Firm <br />Provide FAX Preliminary Results <br />Requested Report Date: <br />11I. Data Validation Report <br />(includes All Raw Data) <br />Firm <br />Firm <br />Date/Time Date/Timek(MDLs/PQLs/TRACE#) <br />RWQCB <br />Date/Time <br />Date/Time <br />RELINQUISHED BY <br />RECEIVED BY <br />Special Instructions/Comments: <br />Container Types Key: <br />40 ml VOA: <br />250 ml LPE: <br />1 <br />2 <br />Signature <br />Signature <br />500 ml LPE: <br />1 liter HDPE: <br />3 <br />4 <br />Printed Name <br />Printed Name <br />500 ml glass: <br />I liter glass: <br />5 <br />6 <br />Firm <br />Firm <br />2x6 s/s ring: <br />glassjar: <br />7 <br />8 <br />Date/Time <br />Date/Time <br />WATER SAMPLE FIELD DATA SHEET <br />FIGURE <br />