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4r r M M r M r mom M M r M M m4r T <br /> CHAIN OF CUSTODY 1 LABORATORY ANALYSIS REQUEST FORM <br /> SHAW Environmental&Infrastracture,Inc. Purchase Order 3648 for 2004' <br /> 1326 North Market Boulevard Sacramento CA 95834 Lab STL,Santa Ana <br /> Project Name Don Rogers Analysis Requested <br /> Project Number 8800391A/01010000 ' <br /> Project Manager David Herzog N <br /> Company SHAW Environmental&Infrastructure,Inc cc <br /> Address 1326 North Market Boulevard v <br /> Sacramento,CA 95834 U °O <br /> Phone 91.6-565-4377 I F 16-565-4a <br /> Sampler's Signature <br /> � x <br /> REMARKS <br /> Sample LAB Sample JConitmner TyM <br /> ID DAtq Time ID Matrix Tedlar I 1presmations <br /> INFL <br /> Vapor 1 1 <br /> EFL I J Vapor I I <br /> MLI QUOEOM BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUMEMENTS X I Routine Report <br /> S Signature Signature Signature 24 hr as hr s day II Report(includes DUP,MS <br /> X Standard(-t IM 5„o&n8 days) MSD,as required,may be <br /> Printed Rame Painted Name Pnnted Name Panted Name PromMe Verbal Pnfirnmaryllesuln charged as samples) <br /> Tim R.Wright PtvndeFAXPeelrrmnary RMIts III Data Validation Report <br /> Firm Furn Firm Firm Requested Report Date (includes All Raw Data) <br /> Shaw E&I In RWQCB <br /> Datr1Fffie t Datar ime DaWTime Date/Tirne (MDLs/PQLVrMCE# <br /> REL QUI]SHED BY RECEIVED BY Special Iirstruetions/Comments Container'Types Kty <br /> 40 ml VOA 1 <br /> Signature Signature STL. 125 ml LPE 2 <br /> f"VN 1711 South Grand Avenue 500 nil LPE 3 <br /> Printed Name Printed Name Santa Ana,Ca 92705 1 liter SDPE 4 <br /> 71425&-86111 fx,258-0921 111 mf,glass 5 <br /> Firm Firm �}� Ms Sabina Sudoko I Iter eaSs 6 <br /> 2x6 s/s rmg 7 <br /> Date(Fmc IDatc/Tune glassjar 8 <br />