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Billing information Analysis/Container/Preservative I Chain of Custody Page_of <br /> Company Name/Address. —' <br /> Fulcrum Resources Env - Monrovia, CA Don Kellar/John Winkler Pres <br /> 415 W.Chestnut Ave. Chk <br /> aceAnalytical a <br /> 415 W.Chestnut Ave. Monrovia,CA 91016 <br /> Monrovia,CA 91016 <br /> Report to: Email To: =O xxms�m, w mw�um:1 rn anxx <br /> forest@frenviro.com;ian@frenvim.com s.emm,ry,�4m,k�„neN "- <br /> v <br /> Forest Kan g DID <br /> Project Description: City/State St��e Easy Please Circle: vef>,anmow..ua.,omm•ei.rw„ra,mm <br /> _. Collected: 7 PT MT CT ET Z N = _ <br /> c _ _ 3 ��o z <br /> Client Project# Lab Project# e m 4+ sDG# <br /> Phone:805-338-8008 ILSL FULRESMCA-FOREST I v a C U u <br /> to : E G Table If <br /> Collected by(print): <br /> Site/Facility ID# P.O.# Z '� d O ------- <br /> 2c)21 C } YEaS L O -h O 2 a E Acctnum:FULRESMCA <br /> �o Est kti� E a <br /> E O O = - E Template:T191696 <br /> Collected by sign Rush? (Lab MUST Be Notified) Quote# 0 O Rr to H Or -T O <br /> _Same Day _Five Day u=. m N ? O Q G a Prelogin:P861801 <br /> _Next Day _5 Day(Bad Only) Date Results Needed ti n iO U to PM:546-tared Starkey <br /> Immediately _Two Day _to Day(gad only) No. W U v m Q > PB:_ _ <br /> Packed on Ice N_ y�. _Three Day of U U O O d - -" <br /> cD # y y to Shipped Via'. <br /> Sample ID Comp/Grab matrix Depth Date Time ntrs W polD <br /> ` Rema,ks samoiezpm omyl <br /> _.- - - -- - ---- - O LD a 3 3 3 <br /> SS3 � o zt WOO 14 1 <br /> to sv :7 1 >C K ~ <br /> 5 t3 2 - v�✓ V 6w zs Jo a r >< x <br /> C7 Vv (s few 2 f04ry } k 4 <br /> GW <br /> GW <br /> GW <br /> GW <br /> •Matrix: emarks: Sample Receipt Chec is— <br /> $-$OII AIR-Air F-Fdier PH Temp COC Seal Present/Intact: NP /Y N <br /> COC Signed/Accurate: iLa _N <br /> GW-Groundwater B-Bioassay Flow_ Other Bottles arrive intact: yz _N <br /> WW-WasteWater correct bottles used: _,if N <br /> OW-Drinking Water Samples resumed via: ¢ 4 tam sufficient vIE A sent: N <br /> T-Other Tracking 7��' O�C� �f IEacelicab'.e <br /> UPS FedEz —Courier VOA Zero Headspace: _N <br /> Date Time: Re by:(Sign tune) Trip Blank Receiv yes N Preservation Correctr: ketl: N <br /> Relinquis ed�ature) [d RAD screen <o.5 mR/hr: 17y _N <br /> "7 G HCL MeoH <br /> A g�>p ree <br /> Relin ed by:(Signature Date: Time: ceived by:(Signature) Temp:I\J W`a Bottles Received: If preservation required by Login:Date/Time <br /> .&/$t csuf <br /> Relinquished by:(Signature) Date: Time: Received for <br /> �lab by:(signature) Dale: Time: Hold: Conditio <br /> 0.s 7 rv__ IL.-e m5 �!7/V J' O �/� NCF /� <br />