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CHAIN OF CUSTODY/ LABORATORY ANALYSIS REQUEST FORM <br /> `0 1433 North Market Boulevard,Sacramento,CA 95834 Service Request No . <br /> fineon ) ( ) 9 Purchase Order <br /> (916 92$-3300 FAX 916 928-3341 Lab Sparger <br /> Project Name Don Rogers Anal sis Requested <br /> Prod-L( Number 22613-100 001 <br /> Pro�W Manager Claudio Avila <br /> 0 <br /> Company EMCON <br /> G � <br /> Address 1433 North Market Boulevard o <br /> Sacramento,CA 834 c °p <br /> Phone (916)928-3300 U <br /> FAX (916)928-3341 o <br /> Sampler's Signature woa <br /> Sam le <br /> 1 D z REMARKS <br /> p LAB Sample 1 Conlamer Types <br /> Date Time I D Matrix NCI <br /> PrLSLfVailnns <br /> MW-1 R water 2 2 <br /> RLIN ISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I Routim Report <br /> Signature _ - ` Signature Signature <br /> �/Z� ��h�7� yV gg' Sig 24 hr 4M hr SdaY 1[ Rcport([ndudesDL1Y MS <br /> IyGGr�r11"( -!,2: rrrL!/�i'1 r`� <br /> 9256� X SWttdard(-i0 i5 wrvkm�days) MSU as rLqutrcd,nt.iy 6e <br /> Punt 4 Name � nnied Name Punted Name Pnnte Imide Verbal Pre imm R=W% <br /> U �' charged as smnplLs) <br /> Finn PruvIde FAX Preliminary R"suti} III Data Validation Report <br /> Fl R <br /> I f a� / Gl t/7 w Firm <br /> Firm cy uested Rc in Da1C (includes Al]Raw Data) <br /> RWQCB <br /> Data Time Date/Time Date/Time DatsJTtme Sid{ (MDLs/PQLs/TRACE#) <br /> RELINQUISHED BY RECEIVED BY Special Instruetroris/Comments Container Types Key <br /> Signature Signature 40 in]VOA 1125 tnl LPE 2 <br /> Punted Nalne Punted Name 500 ml LPE 3 <br /> I liter HDPE 4 <br /> Finn Firm <br /> 500 ml glass S <br /> 1 Ilter glass 6 <br /> 2x6 s/s ung 7 <br /> Uate/Tunr Qatell tine elags tar 8 <br />