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CHAIN OF CUSTODY1 ANALYSES REQUEST FORM (73- 0 <br /> SAMPLE COLLECTOR: PROJECT NO.: SECTION NO.: PATE: a SAMPLER'S IN TIALS: SERIAL Np.: <br /> 4080 Cavitt Stallman S.Rd.,Suite 100 C5f "t)Gi<?21-'Op oUS 1C>"17 G3 � <br /> ra Granite Bay,California 95746-9460, <br /> 5746-9460 PROJECT NAME: SAMPLER(Sgnatur <br /> LEVINE±FRiCxE g16 786.0320 Fax: 916 786-0366 Tatir�$G(J 'j IoC rWC `�/1L: /i / <br /> SAMPLE JANALYSES REMARKS <br /> S <br /> TYPE TAT <br /> 'VOCs: "Metals: <br /> e ° yOryl yyPl Cod' ,41J �`(' 4_ �„ <br /> � ❑ 8260 List ❑ CAM17 <br /> 1 FQ°0 Goc°a weP�eeP� eea'y cele `ePy®\ � P Q a [:18246 List ElRam <br /> 16� <br /> Sample ID. Dae Time °a °ao 6°50� Sad°e5 ,CQ�a,CQgjC��yOGy°Se°�y �'°°�°'��Ui/�l! /'. �aaca��Jg��O�d [1624list ❑ LUF? <br /> Date <br /> SE,,A tl —00 10,1 f M09, 3 1 X I I I I XA L km `S <br /> _0% (J2,1 J \ X COj�l o 1-ioq Ift �tEL <br /> 0`12C <br /> S ,z ta= T <br /> 5�4 - <br /> 13 -'G o Ciq4e 3 x <br /> S!&SA - 11.1 - C)L) oJ44 3 X eft r <br /> rD <br /> t(4 - v(, ico 3 <br /> jggA - IS - ®a , X 'fes - P1 m <br /> Semis - f S - <br /> L01 3 <br /> S e�sA- I(a, - oo (xt 3 X <br /> Sc SA- Ab - 2q oil 3 X <br /> !2G-'S - 1-7 coo 10z, 3 x cs Elsc T n <br /> 3 k 17a 7 1971 <br /> SSA - I a.- OO ID-"41 3 1 1 1 1 1 1b 7LI &LI <br /> sst — IOL2q joqC31 3 1 1 1 1 H Ix <br /> S7t tp - r5� 3 X <br /> 103 3 44X <br /> 20 Vf 4 IPO 3 K <br /> SAMPLE RECEIPT: Cooler Temp: METHOD OF SHIPMENT: INQ (SHED BY: t RELINQUISHED BY: 2 RELINQUISHED BY: 3 <br /> b1T)W-t: ' I�.r�l' �3 <br /> El intact Ell Cold Cooler No: LAB REPORT NO.: (SI REj_. (DATE) (SIGNATURE) (DATE) (SIGNATURE) . (DATE) <br /> ❑ <br /> on ice El Ambient <br /> Preservative Correct? FAX COC CONFIRMATION TO: (PRINTED NAME) (TIME) (PRINTED NAME) (TIME) (PRINTED NAME) (TIME) <br /> ❑ Yes ❑ No ❑ NIA e 1 B <br /> COMPANY COMPANY COMPAN <br /> ANALYTICAL LABORATORY: FAX RESOt.T1�`S TO:.— RECEIVED BY: M1 RECEIVED BY, 2 RECEIVED B�'( O AfORY) ....--- 3 <br /> SEND HA�,RQCOPY TO: (SIGNATURE) (DATE) (SIGNATURE) (DATE) (SIGNATURE) F (DAT m <br /> t�6-g-)tLL cts 7 C✓ P� (G ty 'g <br /> SEND EDD TO: (PRINTED NAME) (TIME) (PRINTED NAPdE) (TIME) (PRINTED"E) ` (TIMEj o <br /> EMV.LABEDDS.CpM T <br /> COPAPANYCOMPANY LABORATORY) (wry <br /> Lab(Shipping Copy (WhiteD. „File Copy (Yellow) Field Copy (Pink} 1 - (, j, / f ,// i, FORM NO: 2001/COC/SXS <br /> :' : , _ - ._. ..c. F]i`.-C` 101:5`,'_} .9.7 i...,a , amu^.-t,� <br />