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CUSTODY 1 LABORATOR ANALYSIS <br /> CHAIN OF CUS REQUEST FORM <br /> Shaw E&I Inc. - 1326 North Market Boulevard,Sacramento,CA 95834 Purchase Order <br /> 916 928-3300 ;:k 91(o-S(c5- 3-5 Labgy <br /> Project Name Don Rogers Anal sIs Requested <br /> Project Number 8800391A/0101Q000 <br /> Protect Manager David Herzog y a <br /> Company %f,-,/ 'rZ C 00 <br /> tn <br /> Address 1326 North Market Boulevard o <br /> Sacramento, CA 95834 <br /> Phone 916-565-4370 / 916-565-435 a <br /> Sampler's Signature <br /> Z I REMARKS <br /> Sample LAB Sample t Crmtamer Types <br /> I D pate Tune I D MatrlX 4r_ Tedlar Preservations <br /> Infl l)0 Air 1 1 <br /> Effl Air I I <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I Routine Report <br /> Si Signature Signature Signature 24 hr 48 hr sday II Report(includes DUP,MS <br /> X standard(—to 15 worhng days) MSD,as required,may be <br /> Pntited Name Printed Narne I Pnnted Name Printed Name Provide Verbal Prehmmary Results charged as samples) <br /> Tun R.Wright Pr"e FAX Prehrrmary Results III Data Validation Report <br /> Firm Firm Firm Firm Requested Report Date (includes All Raw Data) <br /> Shaw E&1 Inc RWQCB <br /> Date/Time Z ( DatelTtme Date/Time Date/Tune (MDLM1QLalTRACE#) <br /> RELINQUISHED BY RECEIVED BY Special Instmetions/Comments —1 Contamer Types Key <br /> .._J+e-trro-, YLQ �(�W�— 40 ml VOA. 1 <br /> Signature Signature Z(p��Z 125 ml LPE 2 <br /> /� 500 ml LPE 3 <br /> Pirated Name Printed Name ell�`"� ] filer HDPE 4 <br /> 500 ml glass 5 <br /> Firm Firni f�JQGJ F�� S 1 liter glass 6 <br /> / 2x6 s/s ring 7 <br /> Date/Time Date/Time G /�/Q� /��/�yy�-� ` iY,4 J KI:sa I 8 <br />