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Attachment 4. Sample Analysis Request Form and Chain of Custody <br />State of California Department of Toxic Substances Control <br />California Pnvirnnmenlal Prmoninn A— <br />ENVIRONMENTAL CHEMISTRY LABORATORY <br />SAMPLE ANALYSIS REQUEST <br />1. Authorization Nuni <br />ECL No.: A - <br />To "'G <br />2. Page <br />1 of 1 <br />1DECO152 <br />3. Requestor.(to Receive Results) a. Name: Dylan. Clark <br />b. Address: 8800 Cal Center Drive tw.r ruwt <br />4. Project Name (if applicable): <br />Sacramento, CA, 9 _ 0". are, W) <br />c. Phone: (916) 2564909 1. rcn.srd) d. Fax: (910)255444_ 1. woe"( <br />e. Email: ddark Cdtsc.n.gov <br />S.TAT Level: 2 <br />6. Sampling Information: a. DmhdTme Sampled: 02"0111 (MnVddlyy) <br />b. Location: EPA ID No. _ _ 11AM-12 PM (9:11E AAMPM) <br />She: OaWW Big <br />Address: 835 Asian twee r.ew.I <br />Stoldtbn, CA (ar. rra xpt <br />GPS-Lat: GPS -Long: <br />GPS -At: GPS -Depth: <br />T. Codes I..l.r Iran heP4 WrMln lfapp w) <br />a. Unit 6aERP.0so m cmllna k oslassvn <br />b. INDEX 4010 <br />aPCA 36322 <br />d. MPC 404 OLA <br />e. SITE 91400848 <br />f. County 39 -am Joaquin_ ---- <br />8. Samples: I. Number of <br />a.ID b. Collectors No. c. ECL Na d. Matrix e. Container Size containers 9. Preservative / Field Information <br />1 B7 ✓ Ink 4 oz clear glass jar 1 _ Kept on ice, pure Ink product <br />2 Oak82 Muitiphask 32 oz dear glass jar 1 Kept on Ice, plan developer <br />__ <br />3 OakB3 A1407RZI al 32 oz dear glass jar 1 Kept on ice, used oil - - — — - - <br />4 OakB4 Multiphasid 32 oz dear glass jar 1 Kept on ice, water based ink with oil <br />8 <br />9 <br />9. Analysis Requested: Falter sample IDs arW sample ID ranges separated by commas. For example, 1-3, 5-7, 9 <br />F <br />a. Inorganic Analysis Sample(&) ID <br />b. Organic Analysis Sampie(s) ID <br />I <br />Metals Screening by XRF (XRF) 2, 3, 4 <br />Flash Point (1020A) 1, 2, 4 <br />_ - <br />_r- <br />E <br />D <br />091ar <br />a. TCLt Anobjeft <br />Id. Other Analysis <br />e. Comrroma for Multiphasic SamplesfA Priorky: <br />10. Analysis Objective: Waste CWfiifieed9n <br />11. Detection Limit Requirements: (Check ECL User's Manual to assure default DL is sufficient.) <br />Need to test for waste classihLa on. <br />12. Supplemental Requests: Enter sample IDs as described in Item 9 <br />Desired AnalysisSamples) ID <br />_ 1I Initials <br />Date <br />13. ECL Lab Remarks: <br />4 <br />s <br />E <br />L <br />14. Chain of Gus <br />Name Tolle Signature bta11Ww Dabs W <br />a. Dylen Clark N.S.S. <br />_ <br />C. ( b <br />d. -- — - — - — - to <br />e.--- ---- - -- -- -- b <br />No <br />c <br />c <br />