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� m4rmwmmm Im4r M <br /> M M M M M M <br /> CHAIN OF CUSTODY/LABORAT ANALYSIS REQUEST FORM <br /> SHAW Environmental&lafrastructure,Inc. Purchase Order 3648 for 2004' <br /> 1326 North Market Boulevard Sacramento CA 95834 Lab STI,,Santa Ana <br /> Project Name Don Rogers Anal is Requested <br /> Project Number $800391A/01020000 ^ <br /> Protect Manager David Herzog civ <br /> Company SHAW Environmental&Infrastructure,Inc C00 <br /> Address 1326 North Market Boulevard o <br /> Sacramento,CA 95834 ccv <br /> Phone 916-565-43771 FAX 91 65-4 5 0 <br /> Sampler's Signature <br /> � x <br /> ° I I I I IREMARKS <br /> Sample LAB Sample 1 Container Types <br /> I D Date Time I D Matrix M Tedlar Preservations <br /> INFL 417-tlasu Vapor 1 1 <br /> EFFL 0 Vapor I I <br /> RELINQUISHED BY RECEIVED BY REUNQUMM BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X 1 Routine Report <br /> Szgnamm Signature Signature u br 43 hr 5 day Il Report(includes DUP,MS <br /> X sriederd(-10-15 working days) MSD,as required,may be <br /> Name Printed Name Printed Name Printed Name Provide Verbal Prelanmary Results charged as samples) <br /> Tim R_Wright PrandeFAXPrehmmaryResults III Data Validation Report <br /> Firm Firm Firm Firm Requssed Report Dm (includes All Raw Data) <br /> Shaw E&11119 RWQCB <br /> DatatTime 'f l DatrlI"1mc DatrdTime Date/Tlme W1-VPQLvTRACE*) <br /> RELINQUSHM BY RECEIVED BY Special Instructions/Comments Container Types Key <br /> 40ml VOA - 1 <br /> Signature Signature STL 125 ml LPE 2 <br /> \ ' 1721 South Grand Avenue 500 ml LPE 3 <br /> Printed Name Printed Name Santa Ana,Ca 92705 1 liter HDPE 4 <br /> 714-258-86101 Fx,258-092I 500 mi glass 5 <br /> Finn Finn \n�� Ms SabmaSudoko I Lterglass 6 <br /> DairlfmleDate rime 2x6 s/s ring 7 <br /> glass�ar 8 <br /> IF <br />