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[ X30 2 0 2=0 <br /> CHAIN OF CUSTODY / LABORATORY ANALYSIS REQUEST FORM <br /> Shaw E&I Inc.-1326 North Market Boulevard,Sacramento,CA 95834 Purchase Order <br /> (916)928-3300 R*Z;=N� 0 4@ Oil" Sic 9110---505- 35 I Lab <br /> Project Name Don Rogers ysis Requested <br /> Project Number 880039.1A 10102Q000 <br /> Campatlyanager David Herzog <br /> ttvt� o ' <br /> N <br /> N <br /> Address 1326 North Market Boulevard <br /> 00 <br /> Sacramento,CA 95834 U <br /> Phone 916-5654370 1 916-565-435 0 <br /> Sampler's Signature x <br /> ' Z REMARKS <br /> Sample LAB Sample �i 1 �� Container Types <br /> Preservations <br /> ID ;Pale Time I D Matrix Tedlar <br /> 111f] ( �' Air I 1 II <br /> EM �`1 0� Air I i II <br /> LL <br /> ' II fl <br /> I II [ <br /> II Il <br /> I <br /> II ![ <br /> II !l <br /> RELINQUISHED BY RE VED B� RELINQUISHED BYI RECEIVED BY TURINAROUND REPORT REQUIREMENTS <br /> 4 ! REQUIREMENTS X I Routine Report <br /> Sr SiSignature I Signature 24 hr _4914 5 day II Report(includes DUP,MS <br /> g�tature <br /> sy A�17— X Standard( 19 15 wore days) MSD,as required,may be <br /> Pr iced Name I Printed Name Printed Name I [ Pnnted Name provide Verbal Preliminary Results charged as samples) <br /> Tim R Wright L.4-5 [ provide FA X Prelrmmary Results III Data Validation Report <br /> Firm I Firm Finn I Firm Requested Report Date (mcludes All Raw Data) <br /> Shaw E&I Inc, � 2-�{2-Z(-V33 Dpi a RWQCB <br /> DatelTime 7- (727D Date/Time Date/Time Date/Time (MDLs/PQLVTRACE#) <br /> RELINQUISHED BY I RECEIVED BY Special Instractions/Comments Container Types Key <br /> 40 ml VOA. 1 <br /> Signature i Signatuiti zlD�J�z �y/� y 125 ml LPE 2 <br /> 500 in]LPE 3 <br /> Printed Name Printed Name I liter HDPE 4 <br /> 500 tnl glass 5 <br /> Firm Firm �Q/ (� � � 1 liter glass 6 <br /> 9z��32x6 sl s 7 <br /> Da Date s 8 <br />