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Rev.1199 <br /> CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 P.O.: <br /> Emcon 916 928-3300 FAX 916 928-3341 Lab: <br /> Project Name: <br /> Analysis R uested <br /> Project Number: a <br /> Project Manager: <br /> Company: EMCON 9 <br /> Address: 1433 North Market Boulevard o <br /> U <br /> Sacramento,CA 95834 a <br /> Plione: (916)928-3300 <br /> FAX: (916)928-3341 <br /> E <br /> Sampler's Sl natu :3 <br /> z REMARKS <br /> Sample IAB Sample ;;:,. Container Tym <br /> I.D. Date Time I.D. Matrix "a Preservations <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT RE,QUIREMENTS <br /> REQUIREMENTS X I. Routine Report <br /> Signature Signature Signature Signature 241W 48 IV— 5 day II. Report(includes DUP,MS <br /> X Standard(-10.13 vrarking days) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Printed Name PrarId.Vabo1 Preliminary Results charged as samples) <br /> Provide FAX Prdimimry Rosuiu III.Data Validation Report <br /> Firm Firm Firm Firm Req aoat,d Rapan owe. (includes All Raw Data) <br /> RWQCB <br /> Date/Time Date/Time Date(Time Daterlimer0�4DLs/PQLeTRACE#) <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Commeuts: Container Types Key: <br /> 40 mi VOA: 1 <br /> Signature Signature <br /> 250 ml LPE: 2 <br /> 500 mi LPE: 3 <br /> Printed Name Printed Name I liter HDPE: 4 <br /> 500 ml glass: 5 <br /> Firm Firm I liter glass: 6 <br /> 2x6 s/s ring: 7 <br /> Dale/Time Date/Time lass'ar. 8 <br /> ��++ <br /> FIGURE <br /> E CON WATER SAMPLE FIELD DATA SHEET ®3 <br />