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• D ORY ANALYSIS <br /> CHAIN OF CUSTODY / LAB REQUEST FORM RA O <br /> 1433 North Market Boulevard,Sacramento,CA 95834 Service Request No I Purchase Order # Page I of l ° <br /> EMC011 (9 16)929.3304 FAX(916)928-3341 Lab <br /> Project Namej1t'� Anal sls R uesied <br /> Project Number Abil-/00 of <br /> Project Manager Claudio Avila <br /> Company EMCON N <br /> Address 1433 North Market Boulevard Q <br /> Sacramento,ISA 95834 U N <br /> Ca <br /> Phone (916)928-3300 �o "' <br /> � <br /> FAX (916)928-3341 � 0 � S z 00 <br /> a Q <br /> Sampler's Signature - - �0 <br /> aQ REMARKS <br /> Z m t•- aC F- o0 <br /> Sample LAB Sample <br /> ID Date Time ID Matrix <br /> 5-30,5 - <br /> I ,s-cB �+ <br /> upi— 5-0- C, 2- <br /> rte, Lc� �► •� " � <br /> RBL 511FD Y IZFCEtVEDBY RbI INQUISHEDBY RECEIVED BY TURNAROUND REPURf REQUIRNh1ENYS <br /> REQUIREMENTS I Routine Rt-poR <br /> Stga use atone Signature Signature Jnr ae to K3 dxy 17 Report(includes DUP MS <br /> lf.+ d F suedvei-,ats, a daytiJ MSD z reWircd my k <br /> Mwed Nam Rni led Name Pnnled Name Panted Name Pronde Vefiat Prcbm nwy Pnulu chargul as svnpks) <br /> /w�17rr�Jo ev,4?— Pn,nk t-A1c PmUm y R-&- iii Data Val-d.mon"Et <br /> Fryr, t i Finn Firm ttequrned RepKt DWe (inrludes Ad Raw Data) <br /> j g G 2 a RWQCB <br /> I)91tll,me Darprl3me Daldr,mr patclitme (MDLvWLsrFRACEit) <br /> RFI INtJfJISHVD BY RF CF VZ"D 61 Special lasirachonsrCommenb Cmiarner Types Kay <br /> 40 int WA t <br /> Stgtr3luvC Signature 125 nil LPC 2 <br /> 5L10 nil LPh 3 <br /> Pnnted Name Pnnied Name I idea IiDPE 4 <br /> 500 ml glass 5 <br /> firm Firm i idea glass $ <br /> 20 ds ung 7 <br /> Dat�llime Uate/frme Idss jar 8 <br />