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Rev.1/99 <br /> CHAIN OF CUSTODY/LABORATORY ANALYSTS REQUEST FORM <br /> 0 1433 North Market Boulevard,Sacramento,CA 95834 P.O.: <br /> 21111LOn 91 928-3300 FAX 91928-3341 Lab: <br /> Project Name: Analysis Renested <br /> Project Number: <br /> Project Manager: e <br /> Company: EMCON <br /> Address: 1433 North Market Boulevard <br /> Sacramento,CA 95834 0 <br /> Phone: (916)928-3300 <br /> FAX: (916)928-3341 E <br /> Sampler's Signatuic, I I IREMARKS <br /> Sample LAB Sample I I lContainerrypes <br /> M <br /> I.D. Date Time I.D. Matrix s� Prescrvuions <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X 1. Routine Report <br /> Signature Signature Signature Signature 24 hr 40 hr� 5 dvy 11.Report(includes DUP,MS <br /> sw,d®,a t-;o.iTZ;ns d,.) MSD,as requited,may be <br /> Printed Name Printed Name Printed Name Printed Name Provide Varb t Prolimhwy Romig charged as samples) <br /> Provide FAX Prei;mi,my Remits 111.Data Validation Report <br /> Firm Firm Firm Firm Requeekd Repen oele: (includes All Raw Data) <br /> RWQCB <br /> Date/Time Date/Time Datelrime Dat crime Ls/P Lar1'RACE <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments: Container Types Key; <br /> 40 ml VOA; I <br /> Signature Signature 250 ml LPE: 2 <br /> 500 ml LAE: 3 <br /> Printed Name Printed Name IliterHDPE: 4 <br /> 500 ml glass: 5 <br /> Firm Firm I liter glass: 6 <br /> 2x6 s/s ring: 7 <br /> Date/Time Daterrime I glassjar: 8 <br /> FIGURE <br /> EMCO=N WATER SAMPLE FIELD DATA SHEET ®3 <br />