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Rev. 1/99 <br /> CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 <br /> FIIKOO 916 928-3300 FAX 916 928-3341 P.O.: <br /> Project Name: Lab: <br /> Project Number: Anal sis Requested <br /> Project Manager: <br /> Company: EMCON cc <br /> Address: 1433 North Market Boulevard o <br /> Sacramento,CA 95834 <br /> Phone: (916)928-3300 ° <br /> FAX: (916)928-3341 E <br /> Sampler's Signatu z <br /> Sample LAB Sample !:' <br /> REMARKS <br /> I.D. Date Time I.D. Matrix Container T es <br /> 0 Preservations <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND <br /> REPORT REQUIREMENTS <br /> REQUIREMENTS X I. Routine Report <br /> Signature Signature Signature g Signature 24 hr 48 hr 5 day II. Report(includes DUP,MS <br /> Printed Name Printed Name X Standard(-10d5 working days) MSD,as required,may be <br /> Printed Name Printed Name Provide Verbal Preliminary Results charged as samples) <br /> Finn Fjnn Firm Provide FAX Preliminary Results III.Data Validation Report <br /> Firm Requested Report Dare: (includes All Raw Data) <br /> Date/Time Date/Time Date/Time RWQCB <br /> Date/Time (MDLs/PQLs/TRACE# <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments: <br /> Container Types Key: <br /> Signature Signature 40 ml VOA: 1 <br /> 250 ml LPE: 2 <br /> Printed Name Printed Name 500 ml LPE: 3 <br /> 1 liter HDPE: 4 <br /> Firm Firm 500 ml glass: 5 <br /> 1 liter glass: 6 <br /> Date/Time Date/Time 2x6 s/s ring: 7 <br /> lass jar: g <br /> FIGURE <br /> E.R.A.CO WATER SAMPLE FIELD DATA SHEET ®3 <br />