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CHAIN OF CUSTODY I ANALYSES REQUEST FORM <br /> SAMPLER'S INITItLS: SERVAL NO.: 0 <br /> AMPLE COLLECTOR: IPROJECT NO !SECTION NO---, DATE: <br /> GUR4080 Cavift StallmanS.Rd.,Suite 100 1,;�—W&245-� - &-20-05 ISA <br /> -9460 PROJECT NAME SAMPLER(Signal <br /> Granite Say,California 95746 <br /> Ke 916 786-0320 Fax: 916 786-0366 <br /> LEVINE-FRIC <br /> SAMPLE V ANALYSES REMARKS <br /> TYPET VOCs: Metals: <br /> 4 8260 List El CAM17 <br /> 8240 List 0 NORA <br /> Sample I D. Date Time 4,11 El 8010 List 0 LUFT <br /> 624 List <br /> Z Ij <br /> xc x I <br /> [Ito I x x I z4AIC -rL 4 <br /> t ------H , <br /> I A 3-DAY -rA--r <br /> CT 2 2 0+31 E <br /> Wr 'M <br /> qg- '196-19-IJ <br /> qM- -74 -6 <br /> F <br /> -Lit <br /> SAMPLE RE(���;METHQD OF SHIPMENT IRkLINQ HE Y; RELINQUISHED BY: 2 RELINQUISHED BY: <br /> ❑ PORT (DATE) (SIGNATURE) (DATE) (SIGNATURE) (DATE) <br /> ❑ Intact ❑ Cold [Zoolw No LA R!EPORTNO.: <br /> On Ice ❑ Ambient L <br /> I ' - <br /> Presewative Correct? FAX COO CONFIRMATION TO; (PRINTED NAME) (TIME) (PRINTED NAME) (TIME) (PRINTED NAME) (TIME) <br /> ❑ Yes [-] No [I NfA <br /> `jPd / COMP COMPANY (COMPANntZ <br /> ANALYTICAL LABORATORY: FAX Rg;kULTS TO: RECEIVED BY: t <br /> RECEIVED BY: 2 RECEIVED p((LABORATORY): <br /> (SIGNATURE) -(DATE) (DATE) (SIGNATURE)SrL, r'ae., SEND HARDOOPY TO: (SIGNATURE) (DATE) <br /> R <br /> SEND BUD TO: (-PRINTED-NME) (TIME) (FRWTED-NAME) (TIME) (PRINTED NAME) I (TIME) <br /> EMV.LABEDDS.COM <br /> ...... ..j. <br /> COMPANY COMPANY <br /> Lab/Shipping Copy (White) File Copy (Yellow) Field Copy (Pink) FORM NO: 2001/COCi$XS <br />