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CEl <br /> m UMAIN U 51 UUYIILbUKAl UKY ANHLYbib htr rUKIVI <br /> rvice05. 3334 Victor Court•Santa Clara,CA 95054 SERVICE REQUEST NO ` {l� P O# PAGE OF <br /> eZ— <br /> (408)748-9700•FAX(408)748 9 6D gSH�'OS$ <br /> 1.4 <br /> PROJECT NAME t�! D LJ �� � � <br /> # +0' I7-wISS NI ANALYSIS REQUESTED <br /> PRESERVATIVE HCI HCRI HCI NP NIP NP HCI HND: NP H 50, Nat}H <br /> PROJECT MGR t9ld221.14 N y r I z 17 �� O <br /> �` m� ( �� <br /> COMPANY 'Call V - <br /> W U o� wow <br /> i�Ui <br /> ADDRESS z m o ro <br /> PHONE C' N� tutu Cr d U o O m m-aa Opp o m <br /> FAX 0 0 a -b r. C'v <br /> SAMPLER'S SIGNATURE m �, co m <br /> 4 O Z'2 �Q1 VvV ,E. <br /> U <br /> SAMPLE LAB SAMPLE te <br /> j o a ro Q== a= ,W,,, 1Vj ro a,o I—x- 2�p REMARKS <br /> D DATE TIME ID MATRIX <br /> sP His I <br /> s � yC�?► O 136II I xx <br /> SP� I�0 -32 II j 61 z <br /> s E A-LP t 9 tIF6 El <br /> !I 1 <br /> it I� <br /> 4ELI� ED BY RECEIVED BY RELINQUISHED BY �) RE CE IVED BY TURNAROUND REQUIREMENTS REPORT REQUIREMENTS <br /> 1 da 2 da 3 da _ I Routine Report <br /> Sig .S t+a-.f,. signature Signature Signature I — <br /> y — y— y II Report(includes MS <br /> day _Other <br /> MSD,as required maybe <br /> Printed Name Printed Name Printed Name Printed Name 1 charged as samples) <br /> 11 1� Standard(10 rking days) — III Data Validation Report <br /> Firt6� l�3or� Firm Firm Firm II t � {includes All Raw Data) <br /> Results Due _ M9I-s1PQLs1Trace# <br /> Date line Date/Time Datemme DateRlme � — Electronic Data Deliverables <br /> RELINQUISHED BYREC� E BY SAMPLE RECEIPT Condition �� jf Custody Seals <br /> SPECIAL INSTRUCTIONS/COMMENTS <br /> Signature Si n t re r Gircle whichmetalspre to be analyzed. <br /> Printed Name Pnnited am� Metals Al Sb Ba Be B Cd Ca Cr "Co Cu Fe Mg Mn Mo Ni K Ag Na Sn V Zn <br /> As Pb Se TI Hg <br /> i <br />� Firm Firm 1 <br /> I I'L <br /> Tim <br /> Datele 4Dalrrirn`eg � ✓ Y j},rl '� �i5D/3 77 <br /> 5 '`o'-�j <br /> Shl2ped Via/Tracking 9 vtC (p 0 5f storage <br /> *Will sample results be used in connection with drinking water regulalions? n Yes 1-1 No it yes,youl must so indicate by writing"DW' for each such sample <br />