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® ® ® ® ® ® ® ® ® ® ® ® ® ® ® ® ® ® ® <br />Rev. 1/99 <br />CHAIN OF CUSTODY / LABORATORY ANALYSIS REQUEST FORM <br />0 1433 North Market Boulevard, Sacramento, CA 95834 P.O.: <br />EMC011 916 928-33UU FAX 916 928-3541 Lap: <br />Project Name: <br />Special Instructions/Comments: <br />Analysis Requested <br />Project Number: <br />Project Manager: <br />c <br />Signature <br />Company: EMCON° <br />Address: 1433 North Market Boulevard <br />0 <br />U <br />Printed Name <br />Sacramento, CA 95834 <br />0 <br />Phone: (916)928-3300 <br />Firm <br />Firm <br />FAX: (916) 928-3341 <br />E <br />Sampler's Signatu . <br />z <br />REMARKS <br />Sample LAB Sample <br />I <br />f <br />container Types <br />I.D. Date Time I.D. Matrix <br />>.... <br />Preservations <br />BY <br />Signature <br />Printed Name <br />BY <br />Signature ISignature <br />Printed Name lPriuted Name <br />BY I RECEIVED BY <br />Name <br />TURNAROUND <br />REQUIREMENTS <br />24 hr 48 hr® 5 day <br />Standard (-10-1i working days) <br />Provide Verbal Preliminan, Results <br />Provide FAX Preliminary Results <br />Requested Report Date: <br />PORT REQUIREMENTS <br />I. Routine Report <br />II. Report (includes DUP, MS <br />MSD, as required, may be <br />charged as samples) <br />III. Data Validation Report <br />(includes All Raw Data) <br />RWQCB <br />RELINQUISHED BY <br />RECEIVED BY <br />Special Instructions/Comments: <br />Container Types Key: <br />40 nil VOA: 1 <br />250 ml LPE: 2 <br />Signature <br />Signature <br />500 ml LPE: 3 <br />1 liter HDPE: 4 <br />Printed Name <br />Printed Name <br />500 ml glass: 5 <br />1 liter glass: 6 <br />Firm <br />Firm <br />2x6 s/s ring: 7 <br />I glass jar: 8 <br />Date/Time <br />Date/Time <br />WATER SAMPLE FIELD DATA SHEET <br />FIGURE <br />-3 <br />