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CHAIN OF CUSTODY /LABORATORY ANALYSIS REQUEST FORM E�Cm) gg <br /> SHAW Environmental& Infrastructure,Inc Purchase Order 3648 for 2004' <br /> 1326 North Market Boulevard,Sacramento,CA 95834 Lab STL,Santa Ana <br /> Project Name Don Rogers Anal szs Requested <br /> Project Number 8800391A/01020000 .. <br /> Project Manager David Herzog a <br /> 0 <br /> Company SHAW Environmental&Infrastructure,Inc <br /> Address 1326 North Market Boulevard <br /> 0 <br /> Sacramento,CA 95834 0 <br /> Phone 916-565-4377/ FAX 16-565-4356 o w <br /> E~ <br /> Sampler's Signature A C7 <br /> � x <br /> Z REMARKS <br /> Sample LAB Sample N1 Container Types <br /> ID Date Time ID Matrix Tedlar Preservations <br /> INFL ;A0101 t$b Vapor 1 1 <br /> EFFL Vapor 1 1 <br /> lip <br /> W <br /> RELINQUISRED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I Routine Report <br /> 4PS;, t <br /> Signa a Signature Signature 24 hr 49 hr 5 day II Report(includes DUP,MS <br /> X Standard(—]0 15 working days) MSD as required,maybe <br /> ed Name Pn ed a Printed Mame Printed Name Provide Verbal Preliminary Results charged as samples) <br /> Tim R Wright �'[ �- Provide FAX Preliminary Results III Data Validation Report <br /> Firm FirmQ Firm Firm Requested Report Date (includes All Raw Data) <br /> Shaw E&I Inc J <br /> Date/Time AWQCB <br /> Date/Time p Date/Time p Q Z <br /> (MDLs/PQLs/TRACE#) <br /> RELINUISHED BY RECEIVED BY Special Instruchons/Comments (� Container Types Kev <br /> �l 40 ml VOA 1 <br /> Signature Signature \� STL 125 ml LPE 2 <br /> LV 1721 South Grand Avenue 500 ml LPE 3 <br /> Printed Name Printed Name ���lll"' Santa Ana,Ca 92705 1 liter HDPE 4 <br /> Firm Firm <br /> \NN O� 714-258-86101 Fx,258-0921 500 ml glass 5 <br /> Ms Sabina Sudoko 1 liter glass 6 <br /> 2x6 s/s ring 7 <br /> Date/Time Date/Time \ las <br /> g sl 8 <br />