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0 <br /> Rev. <br /> j CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> `,,,,f 1433 North Market Boulevard,Sacramento,CA 95834 P.O.: <br /> 8i1K011 91 928-3300 FAX 91 928-3341 Lab: <br /> Project Name: Analysis Reqnested <br /> Project Number: y <br /> Project Manager. <br /> Company: EMCON <br /> C: <br /> Address: 1433 North Market Boulevard j <br /> Sacramento,CA 95834 6 <br /> Phone: (9167 928-3300 <br /> m <br /> FAX: (916)928-3341 <br /> Sampler's Signature. z I I I I I I REMARKS <br /> Sample LAB Sample I JContainerTyM <br /> I.D. Date Time 1,D, Matrix Preservations <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT R-eQUMEMENTS <br /> REQV=,WIENTS X L Routine Report <br /> Signature Signature Signature Signature 241u 4119-- 3 day 11. Report(includes DUP,US <br /> sl.ndad(-t o.ls w1k1.g day,) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Printed Name Prmdda Vorbal Preitminap Rasuka charged as samples) <br /> Praid.FAXNambuuy Rawlu 111.Data Validation Report <br /> Firm Firm Firm Firm Regm.w Ragan D w (includes All Raw Data) <br /> RWQCB <br /> Date/Time DatetTime Date/Time Date(Timc Ls/P L&`RACEt1 <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 /> Datelrime Date/Timclass'ar• 8 <br /> FIGURE <br /> WATER SAMPLE FIELD DATA SHEET -3 <br />