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1083 <br /> CHAIN-OF-CUSTODY/Analytical Request Document Pew: o <br /> aeeAnalyhral BUILDING AMERICA Tne Chaich-Custoq is a LEGAL DOCUMENT All relevant fields must be completed accuretely <br /> Waste Request Only <br /> Section A Section IS Borden C <br /> Required Client Information: Required Project Information. Invoice Information:UPRR-check one <br /> Company:Union Pacific Railroad(UPRR) Repent To: Kelly Fuentes Kelly.Fuentexs@ghd.com She Remediebon Group- <br /> Address: UPRR-Stockton Copy To UPRR-WMQ,c"­�,- Field Operedone <br /> --- REGULATORY AGENCY <br /> 833 E.8th Street Facility Code'.VariousVA-MiseLabinv Engirrearing - <br /> _ NPDES _ GROUND WATERT DRINKING WATER <br /> Email To: Kelly Fuentes(rRand cont Site Loramn Sump Cleaning Solids Greg Martinez <br /> UST _ RCRA r_ OTHE <br /> Phone: 561-293-8477 Fax: UPRR WRs WR# 5230 AIS job no:81046-16 PEDO Site Location Stockton <br /> Requested Due Datearl lab Project# Lab Profits M STATE: CA <br /> Notes:see below <br /> Requested Analysis Filtered(YIN( w,elrreowMm.e i,m.wamire�mw...w.,.m..rc. <br /> - � s <br /> Section Marta Codes a i .nw�n>:mawwa^*..I 1+.000m✓y fix oil>o.om <br /> Rei Cher umermaeee MATRIX/CODE – o COLLECTED Preservatives <br /> Drinking Water DW u z <br /> Water Wr 8 U rwuwsre Owaste <br /> Product <br /> ST <br /> Water WW m O T silbPo0. <br /> rvdupRRae U 0. <br /> cl P m ¢ J '� 2 <br /> So4clld SL <br /> SAMPLE ID O oe � = 0 w a <br /> (Ad.0­9 Ir) Air AR O w a z a f U a L L `o <br /> Sample lbs MUST BE UNIQUE Tissue TS O c. i r ru se r <br /> Other OT U lr \ r 2 z b E <br /> It xS w 4' w O m O c° r ° y i ✓ y R, <br /> w P. \\ LL a 0 p N 5 `m C u le o o \N L p o <br /> 1- <br /> DAM TIME DAiE TIME ug i! M 2 S Z Z f O y w N z O �\` A y K Pace P!O act NOl Lab I.D. <br /> 1 Bin Debris and Sludge#1 S Cr t16 I X x .a <br /> 2 Drums Oily Sludge#2 S c o X I I 1 62 <br /> 3 Drums Oily Sludge#3 S G X _# <br /> X a <br /> 4 Drums Oily Sludge#4 s G f X X X I 5 '\ x r' SS x -Y X J J <br /> X <br /> X 6,z <br /> 7 <br /> e Sample Receipt Checkl t <br /> COC Seal Present/I ntact:_Y11C If Applicable <br /> g COC Signed/Accurate: Y N VOA Zero Headspace: _Y N <br /> 10 Bottles arrive intact: 'f N Pres.Correct/Check: 1' N <br /> Correct bottles used: y u — <br /> ttser:: <br /> 12 <br /> ADDITIONAL COMMENTS RELINQUISHED BY I AFFILIATION DATE TIME ACCEPTEDBY/AFFILIAMN DATE TIME SAMPLE CONDITIONS <br /> 'Please forward initial totals to review R any STLC anmor H �dfr< 2 <br /> TCLP o anolead andlor 96hr fish NRequired is t y C , / . ?.I C33 I`G'` y I N <br /> (please be cognizant of hold times for contingency / <br /> analysis when sending initial toblelAZ6-e— ! //V c, <br /> Melissa (bison @ AIS <br /> SAMPLER NAME AND SIGNATURE c ` <br /> PRINT Name M SAMPLER: 8 z z <br /> g . �8L ET <br /> SIGNATURE of SAMPLER: MTE Bre m to rn <br /> 20-My-2015 <br />