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0 <br /> Rev.1199 <br /> CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 P.O.: <br /> EMCOO 916 9M-3300 FAX 91 928-3341 Lab: <br /> Project Name: Analysis Re uesled <br /> Project Number: <br /> Project Manager: <br /> Company: EMCON a <br /> 0 <br /> Address: 1433 North Market Boulevard v <br /> Sacramento,CA 95834 `o <br /> Phone: (916)928-3300 <br /> FAX: (916)928-3341 E <br /> Sampler's Signatu z <br /> REMARKS <br /> Sample LAB Sample as„` Container Types <br /> I.D. Date T1me I.D. Matrix ° c, 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 M hr.-4s hr_ 5 day u. Report(includes DUP,MS <br /> X fund,d(—to•t5 wmtine dey) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Printed Name Provide vt”Finaminwy Rasaha charged as samples) <br /> Provide FAX mammary R—ft, ' <br /> Data Validation Report <br /> Firm Firm Firm Firm ;t,q—%d Report Dau: (includes All Raw Data) <br /> ' <br /> Date/fimc Date/Time Datc/lime Date/lime RWQCB L LsrrRACEN <br /> RELINQUISHED BY RECEIVED BY Special instructions/Comments. Container Types Key; <br /> 40 mi VOA: I <br /> Signature Signature 250 ml LPE: 2 <br /> 500 ml LFE: 3 <br /> Printed Name Printed Name t liter HOPE: 4 <br /> S00 ml glass: 5 <br /> Firm Firm I liter glass: 6 <br /> 2x6 sts ring: 1 <br /> Datcaime Date/Tiroe lass'ar. 8 <br /> FIGURE <br /> 00 EMC WATER SAMPLE FIELD DATA SHEET A-3 <br />