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Chain of Custody Record 608271 % 7:euro fins . Address: Environment Testing <br />TestAMerica <br />Regulatory Program: _I ow LI NPDES RCRA I Other: <br />Client Contact Project Manager: /Agy,(3.1\ <Jr\ y p. Site Contact: R), SA vp.- Date: X 124b122_ COG No: <br />Company Name C.:ILVA Tel/Email:SW- fi ek _o tivj: Lab Contact: ), 4n:to\ e..5 Carrier: <br />Address- LT ?Voa.,,p, cA01 bp cz,+.. :iitt Analysis Turnaround Time !Filtered Sample ( YIN) I !Perform MS / MSD ( Y / N) 1 0 <br />-.9 <br />0 <br />(YZ) <br />fi <br />0 <br />7 <br />T. - <br />06°C-.) <br />i ..-- <br />ei. <br />_t_ of 14, COCs <br />rSampler : p., <br />City/State/Z ip 4wct e.an Itrtt_ CALENDAR DAYS i . WORKING DAYS For Lab Use Only: <br />Phone Iti, — C%C\ — vii I TAT if different from Below <br />2 weeks <br />1 week <br />2 days <br />i day <br />Walk-in Client! <br />Fax Lab Sampling: <br />Project Name. t1S-9_ — ‘.., i'I'VN(11 tit ViscINYVtif <br />' Site 4)1.1‘9\1)t t--fikv\(-1)) Job / SDG No.: <br />P 0 # <br />Sample Identification <br />Sample <br />Date <br />Sample <br />Time <br />Sample <br />Type <br />(C.Comp, <br />G.Grabi Matrix <br /># of <br />Cont. Sample Specific Notes: <br />S)— rN- \ 1142.2.\3c0 S t i-,i- <br />P — $ \41•1 1 i(..7L.x <br />lr 4)41 <br />s - ic /com05:\e- 1 ,›,z7vc _ <br />si it v , <br />1116171 112- S 1 .... _ <br />1 .. <br />I III 11111 <br />320-84307 I:Than of Gus ody <br />, Preservation Used: 1= Ice, 2= HCI; 3= H2SO4; 4=HNO3; 5=Na0H; 6= Other <br />Possible Hazard Identification: <br />Are any samples from a listed EPA Hazardous Waste? Please List any EPA Waste Codes for the sample in the <br />Comments Section if the lab is to dispose of the sample. <br />. _ <br />Samp <br />, ._ <br />e Disposal ( A fee may be assessed if samples are retained longer than 1 month) <br />Return to Cient Disposal by Lab Archive for _. Months _ Non-Hazard Flammable Skin Irritant Li Poison B H Unknown <br />Special Instructions/QC Requirements & Comments: <br />Custody Se-, cl: ._j Yes _I No Custody Seal No . Cooler Temp. ("C): Obs'd: C 11- Corr'd: Cle3k Therm ID No <br />Relinquished" <br />i <br />Compar6i 1% DaterTi e: /13eaeil <br />1 /7, 12-4, <br />by i / ....1 <br />C49/1/ <br />CorFirfc rf< Dater P' <br />irn I ) 4 2_21_ . <br />I ' Relinquishe. by: Company: Date .me: Received by: Company: Date/Time: <br />Relinquished by: Company: Date/Time: Received in Laboratory by: Company: Date/Time: _