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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 /> FEM(Ofl 916928-3300 FAX 91 928-3341 Lab: <br /> Project Name: Analysis Requested <br /> Project Number, <br /> Project Manager: <br /> Company: RMCON <br /> Address: 1433 North Market Boulevard 0 <br /> Sacramento,CA 95834 0 <br /> Phone: (916)928-3300 <br /> FAX: (916)928-3341 E <br /> Sampler's Signatu z I REMARKS <br /> Sample LAB Sample ContainerTypes <br /> I.D. Date Tlme I.D. Matrix Preservations <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 241. 48 hr 5 day IL Report(includes DUP,MS <br /> X S(aadard(-10.15 eroding days) MSD,as required,may be <br /> Printed NamaPrinted Name Printed Name Printed Name Prm4dc Verbal Pralhnimn'Results charged as samples) <br /> Prmide FAXPrdf.fi-y Ramps III.Data Validation Report . <br /> Firm Firm Firm Finn Ragnastad Raport Data; (includes All Raw Data) <br /> RWQCB <br /> Date/Time Date/Time Date/Thna Date/Time I s/P Ls/TRACEIF <br /> RELINQUISMDBY RECFIVEDBY speciallnatructions/Comments: Container Typos Key: <br /> 40 nil VOA 1 <br /> Signature Signature 250 ml LPE: 2 <br /> 500 ml 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 s1s ring: 7 <br /> DsddTime Date/Time lass'ar S <br /> FIGURE <br /> EMCON WATER SAMPLE FIELD DATA SHEET -3 <br />