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M ® r M ® ® r ® M ® M ® ® M ® ® ® M <br />Rev. 1/99 <br />(4 *1 CHAIN OF CUSTODY / LABORATORY ANALYSIS REQUEST FORM <br />1433 North Market Boulevard, Sacramento, CA 95834 <br />gln(o0 91 928-3300 FAX 916 928-3341 <br />P.O.: <br />Project Name: <br />Lab: <br />Project Number: <br />Analvs is Re nested <br />Project Manager: <br />m <br />Company: EMCON <br />,mom_n <br />Address: 1433 North Market Boulevard <br />c <br />C <br />Sacramento, CA 95834 <br />U <br />Phone: (916) 92$-3300 <br />0 <br />FAX: (916) 928-3341 <br />Sampler's Signatu <br />z <br />Sample LAB Sample <br />REMARKS <br />I.D. Date Time I.D. Matrix <br />Container T es <br />0• <br />0 <br />Preservations <br />0 <br />0 <br />0 <br />0 <br />0 <br />RELINQUISHED BY RECEIVED BY <br />RELINQUISHED BY RECEIVED BY <br />Signature Signature <br />TURNAROUND <br />REQUIREMENTS <br />REPORT REQUIR NTS <br />X I. Routine Report <br />Signature Signature <br />241v 48 hr s dm' <br />R. Report (includes DUP, MS <br />Printed Name Printed Name <br />Printed Name Printed Name <br />X smndn a ( loa3 „•mlcing dny:) <br />MSD, as required, may be <br />Provide Verbal Preliminary Results <br />charged as samples) <br />Firm Firm <br />Provide FAX Prelimiamy Remits <br />11I. Data Validation Report <br />Firm Firm <br />Date/Time Date/Time <br />Requested Report Date: <br />(includes All Raw Data) <br />RWQCB <br />Date/Time Date/Time <br />RELINQUISHED BY RECEIVED BY <br />Special Instructions/Comments: <br />(NDLs/P Ls/TRACE# <br />Container Types Key: <br />40 ml VOA: 1250 <br />Signature Signature <br />ml LPE: 2 <br />500 ml LPE: 31 <br />Printed Name Printed Name <br />liter HDPE: 4 <br />500 ml lass: 5 <br />Firm Firmg <br />1 liter glass: 6 <br />2x6 s/s ring: 7 <br />Date/Time IDatcVTime <br />lass jar: g <br />FIGURE <br />UOE M C 0 IN'1 WATER SAMPLE FIELD DATA SHEET ®3 <br />