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CHAIN OF CUSTODY / ANALYSES REQUEST FORM / t � a <br /> SAMPLE COLLECTOR: PROJECT N \ SECTION O.: DATE: SAMPLER'S INITIALS: SERIAL NO.: <br /> 4080 Cavitt Stallman S.Rd.,Suite IGO ^ ' Zj U 00 G`� o (� 1 9 <br /> 81 Granite Bay,California 95746-9460 PROJECT NAME' f, SAMPLER(Sgnalure: �' j 101 U 80 <br /> LEVINE•FRICKE 916 786-0320 Fax' 976 786-0366 -a /da 'r`"7 Y-C, <br /> SAMPLE _ ANALYSES REMARKS <br /> l TYPE 'V� n< ocF� V 0 TAT 'VOCs: °•Metals: <br /> ❑ 8260 List ❑ CAMI7 <br /> ❑ 8240 List ❑ RCRA <br /> C+ 6 0 '�`(� say �: El 8010 List ❑ LUFi <br /> Sample ID, Date Time �,a ya Sao 4�5o� yaa�es ,�Q'Ta,L¢ �•C`� JOC'y�a�ay�� °�/ yea°,�J`'a0`' ❑ 624 List <br /> 6E21-05-00 1070-2.31125 x X 2:nC,77LC, . <br /> t !—C�6-U �c-z0-u 1130 1� X <br /> c2 -07 DD 0 7� If' ?< X �Zi vdc, STLG <br /> DAV <br /> -r <br /> • u> <br /> CQN lid - '-rYi <br /> UNU fi C C w <br /> m <br /> FT z o L� <br /> c <br /> �n <br /> V <br /> �J(,lhlcS �iSPfi� �` <br /> 916P 818 l �c <br /> 91&— 747:(,�e-P/ <br /> r <br /> ii <br /> SAMPLE RECEIPT: Coale,Temp: MME�THOdDgOF�OIPMENT: RELINQ I$ ED Y: /ry �� �� t RELINQUISHED BY: 2 RELINQUISHEDBY❑ Intact ❑ CWtl CoolerNo: (SI TURF) V DATE) (SIGNATURE) (DATE) (SIGNATURE) (DATE) <br /> ❑ On Ice ❑'Ambient fhP S / �''� ( ` 1 fl <br /> Preservative Correct? FAX COO CONFIRMATION TO: (PRINTED NAME) L-f (TIME) „ '(PRINTED NAME) (TIME) (PRINTED NAME) (TIME) �`1 <br /> ❑ Yes ❑ NO ❑ N/A COMPANY GOMPA <br /> ANALYTICAL LABORATORY: FAXSULTS RECEIVED BY: t RECEIVED BY: 2 RECEIVED B (LABORATORY): 3 <br /> JCr®Yf�S lai2Dlr1 <br /> J <br /> SENO H DCOPY TO: (SIGNATURE) (DATE) (SIGNATURE) (DATE) (SIGNATU ( (DATE) 1? <br /> STL ( ?& Gsn� tGLI�/s7 �,t'ra; {C <br /> ST <br /> SEND EDO TO: (PRINTED NAME) (TIME) (PRINTED NAME) (TIME) (PRI yFED NAME) 3 (TIME) <br /> EMV.LABED6s.COM7(4 S6c,I-�4 rC z �" <br /> COMPANY COMPANY 'flAaORA70RV <br /> Lab/Shipping Copy (White) File Copy (Yellow) Field Copy (Pink) - FORM N0: 2oov000lsxs LII:). <br />