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CHAIN OF CUSTODY / LABORATORY ANALYSIS REQUEST FORM <br /> Pinnacle,3939 Cambridge Road, Suite,220, Cameron Park, CA Service Request No Purchase Order <br /> 9MCOn (530) 676-6884 Fax(530)676-6885 a ci o 0 Cd 8 3 Lab CAS, Santa Clara <br /> Project Name Apache Plastics Analysts Requested <br /> Project Number 22640-100 001 <br /> Project Manager Mark Capps <br /> Company Pinnacle <br /> Address 3939 Cambridge Road, Suite 220 Cqa <br /> Cameron Park, CA 95682 U <br /> Pboue (530)676-6884 k V' <br /> FAX (530)676-6885 0 00 o 00 <br /> Sampler's Signature --t~� x W T W <br /> REMARKS <br /> Sample LAB Sample I lContainer <br /> I D Date Time I D Matrix Preservative <br /> 14P- 1 670 Z-2-31? /I/.;' } water <br /> 16 HS l S <br /> P - L (6 7` 12z-9q 0 W RID <br /> A - 7- -7s /ro <br /> HP - Z o9 q <br /> Boz' 3a I <br /> RELIN UISHED BY RECEI D YRELINQUISHED BY RECEIVED BY TURNAROUND REFOR7 REQUIREMENTS <br /> REQUIREMENTS X I Routine Report <br /> gnature Sig tore 4z <br /> Signature Signature 24 hr 48 hr 5 day 1I P port(includes DUP,MS <br /> —f-stoar—d MSD,as required,may be <br /> Punted Name Pnnt dName Punted Name Punted Name Prrn de Verbal Prdimiffi y Rt Wts charged as samples) <br /> P" ,Ae7meP,w,dc FAX Preliminary F—Wn III Data Validation Report <br /> Fi Firm Firm Requested Repot Date (includes All Raw Data) <br /> 719 y .z 3 ZL91t [� RWQCB <br /> Date/Tim D te/rime Datefrime Date/time (MD1.s/PQLsITRACE#) <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Commentse +F d Container Types Key <br /> t b 1 Rit1 40 ml VOA 1 <br /> Signature Signature Send Samples to CAS,3443 Victor Ct,Santa Clara,CA 95054 �Q 250 mi LPI- 2 <br /> 500 ml LPE 3 <br /> Printed Name Printed Name I liter HDPE 4 <br /> 500 ml glass 5 <br /> Firth Firm I liter glass 6 <br /> Der, 0, L �� l �� 2x6 s/s n 7 <br /> Date/Time Da[e/I'ime � �� glass lar 8 <br />