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ORATORY <br /> d3o56bCHAIN OF CUSTODY l LABANALYSIS REQUEST FORM S <br /> SHAW Environmental&Infrastructure,Inc. Purchase Order 208456 <br /> 1326 North Market Boulevard,Sacramento,CA 95834 Lab Stem Analytical <br /> Project Name Dom Rogers Analysis Requested <br /> ProjectNumber- 8800391A/01020000 <br /> Project Manager David Herzog a <br /> Company SHAW Environmental&Infrastructure,Inc00 <br /> Address 1326 North Market Boulevard 5 <br /> Sacramento,CA 95834 0 <br /> Phone 916-565-4377/ F 916-565-4356 U <br /> c w I <br /> H <br /> Sampler's Signature <br /> ER" REMARKS <br /> Sample LAB Sample ;"a-' IC 1 (I Container Types <br /> I D Date Time I D Matrix �rd�' r dlarll Preservations <br /> INFL b/ Vapor 1 I I II <br /> EFFL 02, Qi7 Vapor I I II <br />� 11 II <br /> II II <br /> 'I II <br /> II II i <br /> 11 II <br /> II II <br /> RELINQUISHED BY i RECEIVED BY RELINQUISHED BY <br /> RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> I REQUIREMENTS X I Routine Report <br /> Si a Signature Signaturel (I Signature 24 hr 49 hr 5 day I1 Report(includes DUP,M5 <br /> [ X standard(-10 15 wading days) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Printed Name Provide Verbal Preliminary Results charged as samples) <br /> Tim R Wright I� Provide FAX Preliminary Results III Data Validation Report <br /> Firm Firm Firm Firm Requested Report nate (includes All Raw Data) <br /> Shaw E&I Inc I RWQCB <br /> Date,rIime Date/Time Date/Time 11 II DateiTime (MDLs/PQLsrrRACE#) <br /> RELINQUISHED BY EIVED BY Special Instructions/Comments Container Types Key <br /> l 40 ml VOA 1 <br /> Signature Signature y� 125 ml LPE 2 <br /> 1�0 '1¢ frF"'1Z Q, Sierra Analytical 500 ml LPE 3 <br /> Printed Name Printed Name 26052 Merit Circle I liter HDPE 4 <br /> —0 v .2, > \� Suite 105 500 nil glass 5 <br /> Firm Firm \n Laguna Hills,Calif 92653 1 liter glass 6 <br /> S• o a •ea u J 2x6 sl 7 <br /> e e g <br />