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CHAIN OF CUSTODY / LABORWRY ANALYSIS REQUEST FORM <br /> IT/EMCON- 1433 North Market BOUILvard,Sacramento,CA 95834 Service Request No Puicliase Order <br /> (916)928-3300 FAX(916)928-3341 Lab SEQUOIA <br /> Project Name Don Rogers Analysis Requested <br /> Project Number IT#792773122613-100 003 <br /> Project Manager Mark Capps C <br /> Company 1T/EMCON 6- oao <br /> Address 3939 Cambridge Road,Suite 220 W <br /> Cameron Park, CA 95682 U Z00 <br /> Phone (530)676-6881 4- x o <br /> FAX (530)676-6885 ° o <br /> Sampler's Signature <br /> z REMARKS <br /> Sample IAB Sample 1120111alflLr types <br /> I D Date I[tile 1 1) Matrix 110 Pfl%fVJIIU[IS <br /> MW-1R )`(Cr1 water 3 3 <br /> REL QUISHED•BY RECEIVED BY RELIHQUISIIED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIRLMENrS X I RoutineRLpurl <br /> Sign ure Si nat re- Signature Signature 2-1 hr 48 hr s tiny 11 Report{includes DUP,MS <br /> X Stand+rd(-l0 15 Harlmy Jays) MSD,as required,may be <br /> Printed Name r P inti aarne �l Printed Name Printed Name Pldrlde Veinal Prclnn2nary Rcsatts Lhargi d as samph s) <br /> Tt �v C', \,5 "L / Provide FAX Pichnnnary Results III DaW Validation RLP0rt <br /> Firm !� Q F + L t Firm rirm Reque ted Report Date (Includes All Ra%% Data) <br /> i+ � •C. t-w t v` R W QCB <br /> Date/time Date/rime DateJlime Date/time (MDIs/PQLs/FRACI-#) <br /> RELINQUISHED BY RE 1 ED BY Special Instructions/Comments Sequoia Analytical Container Types Key <br /> 819 Striker Ave,Ste 8 40 nil VOA i 1 <br /> Signature Signature. SdLlan1l1l10,Ca 95834 125 nil I PE 2 <br /> 916-921-9600 500 m1 1 PE 3 <br /> Printed Name Printed Name ConlaLt Rob Bobel i liter HDPE 4 ' <br /> 500 ini glass 5 <br /> Firm Firm 1 Iuu gLuh 6 <br /> 2x6 515 nag 7 <br /> Iliili/flnio I)uilll IIIIC r1 t s tr '� <br />