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CHAIN OF CUSTODY / ANALYSES REQUEST FORM <br /> SAMPLE COLLECTOR: PROJECT NO.: SECTION NO.: DATE: / SAMPLER'S INITIALS: SERIAL <br /> L1LFRd190 Douglas Boulevard, Sute 200 I O� qq�T0 500501 Granite Bay, California 9574i6-9460 PROJECT NAME:• SAMP (Sign"): 'N2 J 0 0 5 0 1 <br /> LEVINE•FRICKE (9161786-0320 Fax /' Sfccyr0,V <br /> SAMPLE ANALYSES REMARKS <br /> TYPE TAT <br /> 'VOCs: **Metals: <br /> ❑ 8260 List ❑ CAM17 <br /> aFe tGo AQP o�` �Qr �¢P%�e� �R <br /> SAMPLE ID. DATE TIME v5 ° p `a� Pa •t•� •t.9 Q.-F-�Gg �sy% �( /i/aa�/O ❑ 8240 List ❑ RCRA <br /> f! <br /> ay`a1 �J5 a�� ❑ 8010 List ❑ LUFT <br /> SS ❑ 624 List <br /> '�f S� S� <br /> 1>4 Al <br /> DtR�� ILL: <br /> ,✓ 6tL/YYX(7H il/ <br /> SAMPLE RECEIPT: Cooler Temp: METHOD OF SHIPMENT R INOU H 1/a-'1 1 RELINQUISHED BY: 2 RELINQUISHED By 3 <br /> ❑Intact ❑CoM *14", I(O V <br /> ❑On Ice ❑Ambient Cooler No: L REPORT NO.: ( NATURE) (DATE) (SIGNATURE) (DATE) (SIGNATURE) (DATE <br /> 60VA"f GA"vsT, V// /;q- <br /> FAX COC CONFIRMATION TO: (PRINTED NAME) (TIME) (PRINTED NAME) (TIME) (PRINTED NAME) (TIME) <br /> Preservative Correct? L-✓I J <br /> ❑Yes ONO ❑N/A (COMPANY) <br /> (COMPANY) (COMPANY) <br /> ANALYTICAL LABORATORY: FAX RESULTS TO: RECEIVED BY: - 1 RECEIVED BY: <br /> fj <br /> tl I&D BY BORATORYj: ; <br /> y(?( SEND HARDCOPY TO: (SIGNATURE) (DATE) (SIGNATURE) GATE) S NA RE) (DATE <br /> - SEND EDD TO: (PRINTED NAME) (TIME) (PRINTED NAME) (TIME) (P INT NAME) (TIM <br /> V .LABEDDS.COM <br /> (COMPANY) (COMPANY) (COM AN 1 P <br /> v v_ <br /> Shipping Copy(White) File Copy(Yellow) Field Copy(Pink) CHAIN of CUSTODY-ANALYSES FORM,CDR 5/2003 <br />