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CHAIN OF CUSTODY/ Y,ABORATORY ANALYSIS REQUEST FORM <br /> SHAW Environmental& Infrastructure;Inc I Purchase Order <br /> 1326 North Market Boulevard,Sacramento,CA 95834 0 0 3 ! 13 Lab Stena ytical <br /> Project Name Don Rogers �� �f Analysis Requested <br /> Project Number 8&0 391A/01020000 <br /> Project Manager David HerzogLO N <br /> o <br /> Company SHAW Environmental&Infrastructure,Inc C� <br /> Address 1.326 North Market Boulevard r <br /> Sacramento,CA 95834 0 00 <br /> Phone 916-565-43771 F 916-56 -4356 w x <br /> Sampler's Signature <br /> ' REMARKS <br /> Sample LAB I Sample P II 1 Il Container Types <br /> j I D Date Tune I D Matrix 'lTedlarl[ Preservations <br /> WL I 'd 63 07 Yo, DJ Vapor 1 I 1 I[ <br /> EFFL I p?-6p Vapor 1 i 1 I[ <br /> I II II <br /> II II <br /> li I[ <br /> I II II <br /> II II <br /> I II II <br /> RELINQUISHED BY i REVIVED BY RELINQUISHED II Y RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I Routine Report <br /> Slgi I lgnature // Signature Signature 24 hr _40.hT 5 day U Report(includes DUP,MS <br /> 0 m 5c h i./ f Z- I [ X standard(-10.15 working days) MSD,as required,may be <br /> nted Name Printed Name Printed Name I ` Printed Name Provide Verbal Preliminary Resulti charged as samples) <br /> Tim R Wnght 51-Ir E R A , Il Provide 1 AX Preliminary Results III Data Validation Report <br /> Firm I Firm Firm I � Firm Requested Report Date (includes All Raw Data) <br /> Shaw E&I Inc I 3/1"103 07 ,$0 RWQCB <br /> Datc/Tune 3 , O3 I Date/Time Date/Time II [[ Date/Time (MDLs/PQLs/TRACE#) <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments Container Types Key <br /> i - 40 ml VOA I <br /> Signature Signature �1 125 ml LPE 2 <br /> O> Sierra Analytical 500 ml LPE 3 <br /> Printed Name I Pnnted Name 126052 Merit Circle 1 liter HDPE 4 <br /> 1 S utte 105 500 ml glass 5 <br /> Firm I Firm ` I aguna Hills,Calif 92653 1 liter glass 6 <br /> 2x6 s 7 <br /> rine e � S <br />