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CHAIN OF CUSTODY I LABORATORY ANALYSIS REQUEST FORM <br /> Pinnacle,3939 Cambridge Road, Suite 220, Cameron Park,CA Service Request No Purchase Order <br /> EM(OA (530) 676-6884 Fax(530) 676-6885 C�.9 00(080 Lab CAS, Santa Clara <br /> Project Name Apache Plastics Analysis Requested <br /> Project Number 22640-100 001 a <br /> Project Manager Mark Capps <br /> Company Pinnacle sea <br /> Address 3939 Cambridge Road, Suite 220 o <br /> Cameron Park, CA 95682 0 <br /> Pbone (530) 676-6884 w v <br /> FAX (530) 676-6885 ° 0 0 r- <br /> Sampler's Signature w T W W <br /> z C a IREMARKS <br /> Sample LAB Sample lContainer <br /> I D Date Time I D Matrix Preservative <br /> s rP— 1 2—24-1q j 4 Soil X X J� Stockpile <br /> S P - 7- , c X t` t 4 point composite <br /> rP -3 F S <br /> Sr—i° - st <br /> RELINQUISHED BY RECEIV D BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I Routine Report <br /> Signature Sign re Signature Signature 24 hr 48 hr 5 day Il Report(includes DUP,MS <br /> St -Y-standard MSD,as required,may be <br /> Printed NIame Printed tiame Printed Name Pnnted Name Pr—&Vertrai Pmhmtmry Results charged as samples) <br /> �—✓• c0cr Prom&FAX Prd=mouy Results III Data Validation Report <br /> Firm :T/7, T/9 <br /> i T/9 Fi 7 Finn Firm Requested Report Date (includes All Raw Data) <br /> inn[.rr�G /Z;�d 2- Q I W L RWQCB <br /> Dale/Time , Lv Date/I'ime Datefrime Date/Time (MDLs/PQLs(TRACE#) <br /> RELINQUISHED BY RECEIVED BY Special InstructionslComments , l_ Container Types Key <br /> 3�(6 40 ml VOA 1 <br /> Signature Signature Send Samples to CAS,3443 Victor Ct,Santa Clara,CA 95054 250 ml LPE 2 <br /> 500 rat LPE 3 <br /> Pnnted Name Pnnted Name 1 liter HDPE 4 <br /> 500 ml glass 5 <br /> Firm Firm 1 Inter glass 6 <br /> ��+ .� 2x ring 7 <br /> Datefri Date/fime Z�h �� T zrik,-t glib <br /> 8 <br />