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G.? <br />PaceAnalytical' <br />CHAIN-OF-CUSTODY Analytical Request Document <br />Tee Cqamal-Custadyly a LEGAL DOCUMENT Ad reievare reds nest Se ccmpleted accurate, <br />Section A Section B Section C <br />Required C;11,d InfotaAtILA Required Promict Inf.,- .1. ri• Invoice Information <br />sl i <br />1 7 2 2 0 A /1 Aq inc. ,c0i5 R eport To 0 2.42— -L_Pm9-45,1 RAt4u.1.56 "ticiAtEr4 t-tAr-loAscl <br />Address <br />1 V i C.fetv-iiiit R ,J • , <br />Copy To tnk . - • ..— g.. ' .. 6 ' <br />Calvary Nene 9..... REGULATORY AGENCY <br />.1 <br />R.t_Ji iit CA co i•-i1 ",°,-,. 0,.... k.,. rpr.:}s, GROUND WATER DRINKING WATER <br />I-_,&oo____±_mtrmere.„Acc...km 0,, Ji i Pare Ouyie <br />Rename RCRA OTHER <br />Phone Far • CCIINA -'r:. _M • el • f•5 M ,014 • i;" et ''-r"14P4.4" Ee6lyee%) Site LOcation r4 3C)*(t <br />Requested Due Date/TAT P um .5 ' “.... . r'e ' . STATE CIO <br />Reques ed Analys s Rite ed (YIN) <br />Seceen D Matrix Codes <br />irosuiredCiierl Irformnt.n NAIR V t cooT MATRIX CODE (cAeR Waste Wider eiW:.',,t_re SAMPLE 'PIPE (G.GRAEI C,COMP) COLLECTED SAMPLE TEMP AT COI LEC ISIS # OF CONTAINERS Preservat ves <br />Doeung Wee OW <br />Water WY <br />Product R <br />Soil/Solid SL <br />tNA GRA9 <br />I:01 0GS, E Unpreseryed H2S0, HNOHCI Analysis Test , i <br />1,-L Residual Chlorine (Y/N) CO7 8 <br />Lli(Wl‘73 <br />Pace Project No./ Lab 1.0. t <br />SAMPLE ID oil OL <br />Wipe VVP <br />{A-Z.0-9: .-1 As AR <br />a nple IDs MUST BE UNIQUE Tissue TS <br />Otter OT <br />GATE TIME DATE TIME <br />I <br />0 al <br />Z Z <br />. - <br />2 5 <br />I 5 5 - 5‘-/- 1.1 (-0 v -I to) 5 VigitAl lIVI• 137° ) x --'0 ( <br />1100 <br />2 ()S" SVI - C (1)011-0) I <br />Xi 3 SS -51re -5 7-3 012-°) 11 17- I B. 4 5 -S ,41-v.,- 1.3011-0 <br />NIS 5 S5-- FE (2-3011A) <br />0 6 i, 5 - FW(7-3 0 /IP) — -- 11 I 0 s.- <br />s <br />9 <br />10 <br />11 <br />12 <br />ADDITIONAL COMMENTS RELINQUISHED BY. AFFILIATION DATE TIME ACCEPTED BY AFFIIJATION DATE TIME SAMPLE CONDITIONS <br />1 r\C-1 ,1 0Y-, CAnCONsatc) a la is^.5 1FartrAtI kNit c -4-114zo 1 (es 1---7------,'----- ----- -qi 2-11,- R-S- 1 ,1 <br />, <br />--e-r...---0-{ Zir-i----- ,./41-t -el Y/z-- <br />, ..,. <br />iJ .1 3 AA/1 <br />9"oz> '16 <br />ORIGINAL <br />SAMPLER NAME AND SIGNATURE C Le, v• C. <br />8 ci <br />1 i ?T- <br />iTs <br />.14 <br />5. - <br />g <br />E <br />PRINT Simla of SAMPLER <br />SIGNAT UPC of SAMPLER _DAMWOOrIrY4ITE 20 20 <br />Nmportant Now By sNeerer fyI form you am accepong Peres NET 30 del eyelet teen are agreed • . „-. <br />/re) Good 5--,'/5-- <br /> F-ALL 0-020rev 07. 15-May•2007