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Billing Information: Nolnit, Alpha Analytical, Inc. <br /> Company: Broadbant A� Main Laboratory. 255 Glendale Ave, Suite 21 Sparks, NV 89431 Phone: 775-355- 1044 <br /> Attn: nm Babcock C Fax: 775-355-0406 <br /> Address: 1370 Ridgeweod Orin, Sane s 1 Satellite Service Centers: <br /> City, State, Zip: Chico, Calilemia 95973 \ v Northern CA: 9891 Ham Road, Suite C, Rancho Cordova, CA 95827 Phone: 916-366-9089 <br /> Phone Number: 530-566-1400 Fax: <br /> ,7'Ohment�` Northern NV: 350 71h St. Elko, NV 69801 Phone: 775-388-7043 Page 4 of <br /> Consultant/ Client Info: Job and Purchase Order Info: Report Attention/Project Manager: QCDeliverableInfo: <br /> Company Ban <br /> Broadbent Job 4 10.06.161 Name: Tim Bccck EDD Required vas No EDF Required? Yes / No <br /> Address: 1370 Ridgewood Dnva, Surae 5 Job Name: Pilot Flying J e61 B UST Removal Email Address: c- <br /> City, State, Zip: Chico, Caldomia 95973 P.O. c: Phone :: 530.566.1400 Global ID: <br /> Cali 4: 530-s13-0468 Data Validation Packages: III or IV <br /> Samples Collected from which State? (circle one) AR CA\ KS NV OR WA DDD Site Other <br /> Analysis Requested Remarks <br /> Q <br /> e <br /> 'O N J n <br /> U Y m N <br /> O 0 2 <br /> `u m <br /> CD 0 ug <br /> LL G 2 2 V E co m — <br /> Time Date I1 — <br /> Sampled Sampled (Soo Key LL U O> O d U <br /> (1-11-IMM) (MWDD) Below) Lab ID Number <br /> (For Lab Use Only) SarrDle Description TAffT,' IYes ,NO <br /> �{ : So LfwocA � P 1 d U r , X <br /> 11 a <br /> ' S 1 <br /> 1121 -Z Sr. <br /> D3 x x x x <br /> r <br /> ADDITIONAL INSTRUCTIONS: r <br /> 5 SAN J u 64c, 2W <br /> �iC 2o`-�" T Iry Co , 'Ay U .� S J (`n \ , rc <br /> G <br /> I (field sampler) attest to the validity and authenticity of this sample(s). I am aware that tampering with or intentionally mislabeling the sample location, date or time of collection is considered fraud and may be grounds for legal action. NAC 445.0636 (c) (2). <br /> Samp <br /> Reil 'b . (Sign re/Alllll Ion): Dale: Time: Reck d by: (S nature/Alllliation): Dale: Time: <br /> 1 (3 ( 20 1a � 32, / z � z <br /> Reimq ed by. (Signa mhab DalC: Time: Received by. (Signature/Alfiflation): Date: Time: <br /> Relinq ed by: (Signalure/Alfifiation): Date: Time: Received by, (Signature/AOihati n): Date: Time: <br /> Key, AO - Aqueous AR-Air OT - Other SO - Soil WA-Waste : B - Brass L - Liter O - Orbo OT-Other P-Plastic S-Soil Jar T - Tedlar V-VOA <br /> NOTE: Samples are discarded 60 days after sample receipt unless other arrangements are made. Hazardous samples will be returned to client or disposed of at client expense. The report for the analysis of the above samples Is applicable only to those samples <br /> received by the laboralory with thus COC. The liability of the laboratory is limited to the amount paid for the report. <br />