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Rev. 1/99 <br />CHAIN OF CUSTODY / LABORATORY ANALYSIS REQUEST FORM <br />W <br />1433 North Market Boulevard, Sacramento, C.A. 95834 <br />FmcOn 91 928-3300 FAX 916 928-3341. <br />P.O.: <br />Project Name: <br />Lab: <br />Project Number: <br />Analsis Re nested <br />Project Manager: <br />c <br />Company: EMCON <br />}g <br />Address: 1433 North Market Boulevard <br />U <br />Sacramento, C.A. 95834 <br />0 <br />Phone: (916) 928-3300 <br />FAX: (916) 928-3341 <br />E <br />Sampler's Signatu . <br />Z <br />Sample LAB Sample it <br />REMARKS <br />I.D. Date Time I . Matrix ""' <br />ContainerT es <br />Preservations <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />RELINQUISHED BY <br />RECEIVED BY <br />RELINQUISHED BY RECEIVED BY <br />TURNAROUND <br />REPORT REQUIREMENTS <br />Signature Signature <br />REQUIREMENTS <br />X1. Routine Report <br />Signature <br />Signature <br />241v ds hr 5 dm' <br />H. Report (includes DUP, MS <br />Printed Name Printed Name <br />Stn do d (-1e-13 noddna d.m <br />Provide Verbal Proiim -y Ramhr <br />MSD, as required, may be <br />charged as samples) <br />Printed Name <br />Printed Name <br />Firm Firm <br />P—id. FAX P1o11m11-y R ... IU <br />III. Data Validation Report <br />Firm <br />Firm <br />Ro4aonmd Repo,] nom: <br />(includes All Raw Data) <br />Date(Time Date/Tinto <br />RWQCSLs/P Ls/TIZACEM <br />s/PQ ) <br />rRACETypes <br />Date/Time <br />Date/Time <br />RELmQUISIIED BY <br />RECErVED BY <br />Special Instructions/Comments: <br />C er <br />40 ml VOA: 1 <br />Signature <br />Signature <br />250 ml LPE: 2 <br />500 ml LPR 3 <br />1 liter HDPE: 4 <br />Printed Name <br />Printed Name <br />500 ml glass: 5 <br />Firm <br />Firm <br />1 liter glass: 6 <br />2x6 s/s ring: 7 <br />lass 'ar. 8 <br />Date/rime <br />Date/Time <br />FIGURE <br />dt E CON WATER SAMPLE FIELD DATA SHEET _3 <br />