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Rev.9/99 <br /> a CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 <br /> EMC 91 928-3300 FAX 916 928-3341 P.O.: <br /> Project Name: Lab: <br /> Project Number: Anal sis Requested <br /> Project Manager: <br /> Company: EMCON <br /> Address: 1433 North Market Boulevard U <br /> Sacramento,CA 95834 <br /> Phone: (911)928-3300 <br /> FAX: (916)928-3341 n <br /> Sampler's Signafil� z <br /> Sample LAB Sample i REMARKS <br /> I.D. Date Time I.D. Matrix ContainerT es <br /> 0 Preservations <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND IMPORT REQUIItEMENTS <br /> Signature Signature REQUIREMENTS X I. Routine Report <br /> Si nature P <br /> g Signature z4 Its 49 hr 5 day IL Report(includes DUP,MS <br /> Printed NameX Standard(-10.13,%wI,Ing days) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Proridc Vcrbal Prdim{nnn•Rcsnitr charged as samples) <br /> FirmProcidc FAX Preliminary Results III.Data Validation Report <br /> Firm Firm FirmRequested Repo; (includes All Raw Data) <br /> Acle: <br /> Date/Time Date/TimeRWQCB <br /> Dalrylime AatelFime QVMIDL/P Ls/TRACE# <br /> RELINQUiMD BY RECEIVED BY Special Instructions/Comments: <br /> Container Types Key: <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 /> Datelrime DatclTime 2x6 s/s ring. 7 <br /> lass"ar. 8 <br /> 'i,Wj I C ��++ FIGURE <br /> !_. C WATER SAMPLE FIELD DATA SHEET ®3 <br />