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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 /> 9MC00 91 928-3300 FAX.91 928-334 Lab: <br /> Project Name: Anal sis Re nested <br /> Project Number. <br /> Project Manager. <br /> Company: EMCON .B <br /> Address: 1433 North Market Boulevard <br /> Sacramento,CA 95834 `a <br /> Phone: (916)928-3300 <br /> FAX: (916)928~3341 8 <br /> Sampteessign ZI I I I I I I I I I I REMARKS <br /> Sample LAB Sample Co ta(ner <br /> I.D. Date I Time I.D. Matrix ovations <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 01INQUISHED BY RECEIVED BY RELINQUISHED BY RECUVEA BY TURNAROUND REPORT REQUMR MINTS <br /> REQULRSMMNTS X 1. Routine Report <br /> Signature Signature Signature Siganmre 14hr+sh^ sa.y 11. Report(includes DUP,MS <br /> swZ(-t ats.w ktes d.,) MSD,as required,may be <br /> Printed NamePrinted Name Printed Name Printed Name charged as samples) <br /> PrvvW FAX P".11Wns y XxJm III,Data Validation Report <br /> Firm Film Firm Firm aoq.ra ft."done (includes All Raw Date) <br /> RWQCB <br /> �ate/Timo RetelimeDate/time 1Datelrfmo Ls/IRAACS <br /> RELINQUISHED BY PII:CEIVE0 BY Special Instruelionstcommentr. Container Types Key. <br /> 40 mi VOA: I <br /> Signature Signature 250 ml LPE: 2 <br /> 500 ml LPE: 3 <br /> Printed Name Printed Name I liter MPE: 4 <br /> 500 mi glass 5 <br /> Firm Firm I liter glass: 6 <br /> 2x6 sts ring: 7 <br /> Dote rime Vole/Time lass'ar: 8 <br /> FIGURE <br /> U0EMCON WATER SAMPLE FIELD DATA SHEET A.®3 <br />