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CHAIN OF CUSTODY / LABOR&RY ANALYSIS REQUEST FORM - <br /> 1433 North Market Boulevard,Sacramento,CA 95834 Service Request No Purchase Order <br /> I: ICC}f1 (416)928-3300 FAX(916)928-3341 Lab SEQUOIA <br /> Project Name Don Rogers Analysts Requested <br /> Project Number 1T#792773/22613-100 003 <br /> Project Manager Mark Capps o <br /> N <br /> Company IT/EMCON � 0 <br /> Address 3939 Cambridge Road,Suite 202 <br /> Cameron Park,CA 95682 0 00 <br /> Phone (530)676-6881 U X .. <br /> FAX (530)676-6885 0 01 <br /> N <br /> 00 <br /> Sampler's Signatureei <br /> m <br /> z REMARKS <br /> Sample LAB Sample I Container Types <br /> I D Date Time I D Matrix HCI Preservations <br /> MW-1R $Cpl lb T/ water 3 3 <br /> REL I QUI E EIYED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> RLQUIREMENTS X I Routine Report <br /> n lure Sig reU Signature Signature 24 hr 48 hr s day 11 Report(includes DUP.MS <br /> ✓lam,- Slandard(—t0.lSworlengdays) MSD,as required,may be <br /> anted Name Pmt Name rp Printed Name Printed Name Provide Verbal Preliminary Resitln charged as samples) <br /> C,S v r Provide FAX Preliminary Results 111 Data Validation Report <br /> Firm Fir Firm Firm Requested Report Date (includes All Raw Data) <br /> ; �? 9f 'd o 4 1 Ct RWQCB <br /> Daterrime DatelSsmi 420 Date/Time Date/time (MDLs1PQl s/IRACEfi) <br /> RELINQUISHED BY REC BY Special Instructions/Comments Sequoia Analytical Container Types Key <br /> 819 Striker Ave,Ste 8 40 ml VOA t <br /> Signature Signature , Sacramento,Ca 95834 125 ml LPE 2 <br /> i <br /> 916-921-9600 500 ml LPE 3 <br /> Printed Name Printed Name , Contact Rob Babel I liter HDPE 4 <br /> r <br /> 800 ml glass 5 <br /> Firm Firm I liter glass 6 <br /> 26 sls ring 7 <br /> Date/rime Date/time glass jar 8 <br />