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CHAIN OF CUSTODY 1 LABORA&Y ANALYSIS REQUEST FORM <br /> (5*1433 North Market Boulevard,Sacramento,CA 95834 Service Request No Purchase Order <br /> EMCOII (916)928-3300 FAX (916)928-3341 Lab SEQUOIA <br /> Project Name Don Rogers Anal sis Requested <br /> r)rolect Number 22613.100 003 <br /> ,-Toject Manager Mark Capps o <br /> Company EMCON-Pinnacle <br /> Address 3939 Cambridge Road,Suite 202E <br /> o E <br /> Cameron Park,CA 95682 U °O o <br /> Phone (530)676-6881 0 S 3 <br /> FAX (530) 676-6885 <br /> Sampler's Signature w <br /> z I fREMARKS <br /> Sample LAB Sample 1 1 Container T s <br /> ID Date Time ID Matrix HCl HCl Preservanons <br /> MW-111 water 5 3 2 <br /> REI iNQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I Routine Report <br /> Sag at Signature Signature Signature 24b 48 lar 5day 11 Report(includes DUP,MS <br /> 4&;lTL - suodalyd(.-ta 15 watme days) MSD,as required,may be <br /> 7ted Name Printed Name Printed Name Pnnted Name P=Vb&Verbs)Pvdmmary ResNq charged as samples) <br /> �hL1 Pron&FAX fti mmuy ResWu III Data Validation Report <br /> Fimi Farm Firm Firm Reques"Report Dale (includes All Raw Data) <br /> -AG>'7L-G7? 4, <br /> Date/Time DaW RWQCB <br /> lime Dai vTirrie Date/Time (IWQCBQLsII RACEII) <br /> RELINQUISHED BY G~ RECEJUD BY Special Instructions/Comments Sequoia Analytical Contauter Types Key <br /> 819 Sinker Ave,Ste 8 40 ml VOA 1 <br /> Signature S Sacramento,Ca 95834 125 ml LAE 2 <br /> L 916 921-9600 i 500 ml LPE 3 <br /> Fronted Name Pnn ane Contact Rob Bobel I later HDPE 4 <br /> 1 500 ml glass 5 ' <br /> Firm F", O D�/ I liter glass 6 <br /> a 2x6&Is ring 7 <br /> Date/Iame Da im glass jar 8 <br />