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Rev,1/99 <br /> CHAIN OF CUSTODY/]LABORATORY ANALYSIS REQUEST FORINT <br /> 00 1433 North Market Boulevard,Sacramento,CA 95834 P.O.: <br /> FMCOf) 914 928-3300 FAX 91 928-3341 Lab: <br /> Project Name: Analysis R uested <br /> Project Number: rn <br /> Project Manager: c <br /> Company: EMCON ° <br /> Address: 1433 North Market Boulevard ° <br /> U <br /> Sacramento,CA 95834 0 <br /> Phone: (916)928-3300 <br /> FAX: (916)928-3341 <br /> Sampler's Signatu . z I I I I I I I I I I I I I I I I I REMARKS <br /> Sample LAB Sample `" Container Types <br /> I.D. Date Time 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,r_48hr_ 5 day 1I. Report(includes DUP,MS <br /> X Swidard(-10-15 wor«ing days) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Printed Name Provide Varbal Preliminary R—lu charged as samples) <br /> Provide FAX P¢fiminary Results IIl.Data Validation Report <br /> Firm Firm Firm Firm Requested Report Datc: (includes All Raw Data) <br /> RWQCB <br /> Date/Time Date/Time Date/Time Date/Time LsT LS/rRACE# <br /> RELINQUISHED BY RECEIVED BY Speciallnstructions/Comments: Container Types Key: <br /> 40 ml VOA: 1 <br /> Signature Signature 250 ml LPE: 2 <br /> 500 ml LPE; 3 <br /> Printed Name Printed Name 1 liter HDPE: 4 <br /> 500 ml glass: 5 <br /> Firm Firm 1 liter glass: 6 <br /> 2x6 s/s ring: 7 <br /> Date/Time Date/Time lass'ar: 8 <br /> PIG U RE <br /> UZEMCON WATER SAMPLE FIELD DATA SHEET �. <br />