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M M = M M M MM <br /> = = = M - <br /> CHAIN OF CUSTODY / LABORATOR ALYSIS REQUEST FORM <br /> hasv E& I Inc.-1326 North Market Boulevard,Sacramento,CA 95834 Purchase Order # 189246 to <br /> (916)928-3300 FAX(916)928-3341 Lab Sparger Tec ltxt-lo <br /> kn <br /> 'rolect Name Don Rogers Anal sis Requested <br /> 'ro1ect Number 9800391A/01020000 <br /> 'mject Manager David Herzog o <br /> onipany Shaw E & I Inc. g °�° <br /> iddress 1326 North Market Boulevard <br /> � o <br /> Sacramento,CA 95834 U <br /> 'hone 916-565-4370 1 F -565 56 o X <br /> -ampler's Signature r <br /> z REMARKS <br /> Sample LAB Sample 4 I Container Types <br /> I D DAtj Time I D Matm\ - redlar Preservations <br /> Infl S VAPOR 1 I <br /> EM O Q VAPOR I 1 <br /> tELINQUISHED BY EIVED RELINQUISHED BY RECEIVED B1' TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I Routine Report <br /> IL-T , Stgnariire Signature 24 hr 4e to 5 day 11 Report(includes DUP,MS <br /> NAA r <br /> � X stasraardt-10-15wurl,uigday>1 hISD,as required,may be <br /> 'rtnted Name PtrrrM ante nted Name Printed Name Provide Verbal Prehmmary Results charged as samples} <br /> un R Wright Prmde FAX Prnl Mm Rrssdts _III Data Validation Report <br /> tmt Ft tit Fnmi Firm Requested RTost Date (includes All Raw Data) <br /> haw E&I Inc RWQCB <br /> )atelran> Dat une DatelTime DatclTune (MDLs/PQLs/TRACE#) <br /> RELIN ft3HEDBY CEIVED BY Special InstructionslConunents Coertamer Types key <br /> 40 ml VOA- 1 <br /> ignature Signature 125 int LPE 2 <br /> Sparger Tech 500 til LPE 3 <br /> rented Name, Pnnted Name 3050 Fite Cimle,Ste 112 1 Inter HDPE 4 <br /> Sacto Calif 95827 500 nit glass 5 <br /> imt Furst 916-362-8947 t F\362-0947 t liter glass 6 <br /> _ 2%6 sis ring 7 <br /> )ateTinu Date-Tune __ glamlar 9 <br />