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CHAIN-OF-CUSTODY Analytical Request Document
<br />ace Analytical' cha,n_cf-custody s a LEGAL DOCUMENT - Complete all relevent fielcl
<br />LAB USE ONLY- Affix Workorder/Login Label Here or List Pace Workorder Number or
<br />MT.IL Log-in Number Here
<br />L 14 Z 7 ct Lt s,
<br />ALL SHADED AREAS are for LAB USE ONLY Company:
<br />ATC/ Atlas, San Ramon
<br />Billing Information:
<br />"Ku). "i--) Valcook,—
<br />too, (.....,-, (a nv)rs cZ 01 Isalt-C er 2. Lo
<br />Prt-se-v T'LE.E. • • :ontairer a: ye L ab Project Manager: Add ress. 2001 Crow Canyon R8. Suite 210, San Ramon, CA, 94583 sax, iza ,.,,, (A_ 4 q a.-."
<br />I
<br />Report To: Matt Livingston, Michelle Berube Email To: mad uengstoniZoneaUas corn
<br />nenege berubegonsatlaawm
<br />• 'eser vative Types (I) nitric acid, (2) sulfuric acid, (31 hydrochlo ic acid, (4) sodium hydroxide, (S) zinc acetate,
<br />i: -ethano, (71 sodium bisulfate, 181 sodium thiosulfate, (9) hexane, (A) ascorbic and, (9) ammonium sulfate,
<br />- i-nrnorsum hydroxide, (D)T5P, (U) Unpreserved, 101 Other Copy To: nnichelleterube©oneatlas.com
<br />Site Collection info/Address:
<br />23975 E Milton Rd Analyses Lab Profile/Line:
<br />Customer Project Name/Number:
<br />Bonnie Plants- Linden
<br />State: County/City: Time Zone Collected:
<br />-.cceniCA [frirPT [ ) MT j (CT [JET Soil DRO/ORO-CA 8 oz Clr-NoPres Soil GRO-CA 40m1Amb/Me0H10m1/Syr Title 22 Metals SoI VOCs 8260 40m1Arnb/Me0H10m1/Syr Lab Sample Receipt Checklist :
<br />Custody Seals eresent/intaof ' NA
<br />mstody Slor..-_..,:res Present N NA
<br />— • ' - ..,:•,:- 1:- - :r ,,:•zre Present 0 N NA
<br />(t7t1 NA
<br />_ .,-_-._les 4:9 11 NA
<br />s..,:-.:: _.7.:.enl-, 'Volume nJ NA
<br />Samples Received on Ice (TX NA
<br />VOA - Headspace Acceptable Y N
<br />USDA Regulated Soils
<br />Samples in Holthng Time 61N NA
<br />Residual Chlorine Present Y N 0
<br />Cl strips:
<br />Phone: 4-1.5-_ti 40 ....5; e o
<br />Email: matt liyingsiongoneatlas corn
<br />Site/Facility ID if: Compliance Monitoring?
<br />1 1 Yes I ) No
<br />Collected By (print):
<br />Michelle Berube
<br />Purchase Order #:
<br />Quote it:
<br />DW PWS ID 14:
<br />OW Location Code:
<br />Collected By (Si . ure • • und Date Required: immediately Packed on Ice:
<br />IVYes I [ No
<br />Sample Disposal:
<br />[ I Dispose as appropriate ( (Return
<br />[ I Archive.
<br />Rush:
<br />( j Same Day [ 1 Next Day
<br />[ I 2 Day I 13 Day I [ 4 Day v 5 Day
<br />Field Filtered (if applican i-i
<br />I I Yes ( I No
<br />Sample pH Acceptable Y 0
<br />pH Strips: Analysis: [ (Hold: (Expedite Charges Apply) Sulfide Present Y NO
<br />Lead Acetate Strips: Matrix Codes (Insert in Matrix box below): Drinking Water OW), Ground Water (GW), Wastewater (WW),
<br />Product (P), Soil/Solid (SL), Oil (OL), Wipe (WP), Air (AR), Tissue (TS), Bioassay (B), Vapor (V), Other (OT) .AS USE ONLY:
<br />Lab Sample Ir / Comments:
<br />Customer Sample ID Matrix '
<br />Comp /
<br />Grab
<br />Collected (or
<br />Compos te Start)
<br />Composite End
<br />Res
<br />Cl
<br />it of
<br />Cl'-
<br />Date Time Date Time
<br />Waste Profile # 1 SS Comp 11/4/21 1424 11/4/21 1424 3 X X X, X
<br />,
<br />_.
<br />Customer Remarks / Special Conditions / Possible Hazards: Type of Ice Used: Wet Blue Dry None SHORT HOLDS PRESENT (<72 hour ): Y N N/A Lab Sample Temperature Info: , -)
<br />TT ehemrpmBilDattnk Received: Y61/ NA PackIng Material Used: Lab Tracking U: 9 st,741 c",
<br />6 t(_} 75/(--) • Cooler 1 Temp Upon Receipt: oC
<br />Radchem sample(s) screened (<500 cpm): Y N NA
<br />Sampl re eived via:
<br />D UPS Client Courier Pace Courier
<br />Cooler 1 Therm Corr. Factor: oC
<br />Cooler 1 Corrected Temp: oC
<br />Comments: Relinquished by/Compan " (Si mature) Date/Time: /630 Received by/Company: (Signature) e/Time: A179 _
<br />— Acctnurn:
<br />Relinquished by/Company: (Signature) Date/Time Received by/Company: (Signature) Date/Time:
<br />Template:
<br />Prelogin:
<br />Trip Blank Received: Y (N ,.i NA
<br />HCL MeOH TSP Other
<br />Relinquished by/Company: (Signature) Liate/Time: Reieived by/Company: Signature
<br />( S'Ili". - aL-
<br />Date/Time' .
<br />i ill ./ //)/ 6734)PB:
<br />PM: Non Conformance(s):
<br />YES / NO
<br />' a g i' :
<br />.)f:
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