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CHAIN OF CUSTODY / LABORATORY ANALYSIS REQUEST FORM <br /> IT/EMCON- 1433 North Market Boulevard,Sacramento,CA 95834 Service Request No Purchase Order <br /> (916)928-3300 FAX(916)928-3341 Lab SEQUOIA <br /> Project Name Don Rogers Analysis Requested <br /> Project Number ITN 792773/22613-100 003 <br /> Project Manager Mark Capps o^ <br /> Company IT/EMCON <br /> Address 3939 Cambridge Road,Suite 220 W <br /> Cameron Park,CA 95682 <br /> Phone (530)676-68$1 X o <br /> FAX (530)676-6885 ° � o <br /> Sampler's Signature <br /> REMARKS <br /> Sample LAB Sample I Container Types <br /> I D Date Time I D Matrix HCI Preservations <br /> MW-IR Z L cb i3 s water 3 3 t <br /> REL IED R'1' RECEIV RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I Routine Report <br /> S!gM <br /> Signal;-le Signature Signature 2d hr as hr - 5 day ,ll Report(includes DUP,MS <br /> 4 X Standard(-10 15 working days) MSD,as required maybe <br /> Pnmec(� r Printed Nam Printed Name Printed Name Provide Verbal Preliminary Resalts - charged as samples) <br /> Provide FAX PIelunmary Results ill Data Validdtion Report <br /> FirmFtrrn Firm Firm Requested nDate <br /> � � ey po (includes All Raw Data} <br /> d <br /> R WQCH <br /> Dale£l lmc. Date£rimu DatetTlme DateMine (MDI s/PQI s£I RAC E#) <br /> RE[1NQtfI511ED B1 <br /> RECEIVED BY Special IDstructions/Couiments Sequoia Anal}ttcal Container 7 ypes Key <br /> 819 Sinker A%,. Ste 8 aU till VOA I <br /> Sign�lul� Signa rz" - s <br /> Sac,wwunto Ca 95831 12)nil I Ill 2 <br /> 7 C I 916 921 900 )00 lilt I Pt 3 <br /> Prinh_d Nd111L C uota,,t Rub liubel 1 Iltr t I IDPE A <br /> )Utl nil Ll&u] 'IE EFIII <br /> !I Ill — <br /> 71 <br /> I lirU_11]D O <br /> Datt.£I ung—_���_� ---t)atL1 Imo <br /> � � �� �� � Ali � I♦ � � � � � � it i� ��R i <br />