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CHAIN OF CUSTODY/LABORATORY ANALYSIS REQUEST FORM <br /> SHAW Environmental&Infrastructure,Inc. Purchase Order 208456 <br /> 1326 North Market Boulevard,Sacramento,CA 95834 Lab Sierra Analytical <br /> Project Name Don Rogers �f (� Analysis Requested <br /> Project Number- 8800391A/01020000 <br /> Project Manager David Herzog 1 <br /> Company SHAW Environmental&Infrastructure,Inc. <br /> Address 1326 North Market Boulevard 9 I <br /> Sacramento,CA 95834 c <br /> Phone 916-56543771 F 916-5654356 <br /> � o <br /> Sampler's Signature -�—� <br /> I <br /> H REMARKS <br /> Sample AB Sample I III Container Types f <br /> I D Date Time I D Matrix11 Tedtar Preservations <br /> INFL WVapor 1 III I <br /> EFFL Vapor 1I III <br /> 11 II ` <br /> II II <br /> ' II II <br /> �l II <br /> 11 II 3 <br /> 11 II <br /> 11 II <br /> RELINQUISHED BY IRECEIVEDRY RELINQUISHED�fB1 (I RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> — - 4 1, II f , <br /> REQUIREMENTS X I Routine Report <br /> Si a Signature Signature f II Signature u hr 4s hr 5 day lI Report(includes DUP MS <br /> Ik Standard(—[0 35 workmg days) MSD,as required,may be <br /> i <br /> Printed Name Printed Name Printed NameII Printed Name Provide Verbal Preliminary Results charged as samples) <br /> Tlm R Wright !I Provide PAX I'mirmmaryResults IR Data Valldatzon Report <br /> Firm Firm Firm Firm I Requemed Report Date (includes All Raw Data) <br /> Shaw E&I Inc II RWQCB <br /> Date/Tlmz J)WDate/Time Date/Time ]I II Date/Tlme (MDLsIPQL sIIRACE#) <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments Container Types Key <br /> 40 ml VOA 1 <br /> Signature Signature 125 ml LPE 2 <br /> N Sierra Analytical 500 ml LPE 3 f <br /> Printed Name Printed Name �N 26052 Merit Circle 1 liter HDPE 4 i <br /> V''J Suite 105 500 ml glass 5 <br /> Firm Firm a° Laguna Hills,Calif 92653 1 liter glass 6 1 <br /> 2x6 7 <br /> _ II <br />