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i <br /> CHAIN OF CUSTODY 1 LABORATORY ANALYSIS REQUEST FORM 7© <br /> 1433 North Market Boulevard,Sacramento,CA 95834 Service Request No Purchase Order # Page 1 of <br /> I IC011 (916)928-3300 FAX (916)928-3341 l ab <br /> F <br /> tName DONR4t76 Aal sis Re uested <br /> t Number .Zia 173-100 0 � At Manager Claudio Avila <br /> Company EMCON <br /> Address 1433 North Markel Boulevard btti p q <br /> Sacramento,CA 95834 U ,� Cy <br /> r N <br /> Phone (916)928-33000 <br /> oo U <br /> FAX (916)928-3341 a 0 1 <br /> Sampler's Signature <br /> 4 Q z REMARKS <br /> Sample LAB Sample <br /> ID Date Time ID Matrix <br /> 11- 6 to it 116 <br /> RFI "V ISHF U BY <br /> IF IVF F I INQUISHFD BY RECEIVED 111 TURNAROUND RLPORT RF QUIRI h11 N r% <br /> RF QUIRf:MF NTS I Routine Repan <br /> SiJ`�toJ Signature Signature Signature 241v 4ehr 5e.y tl Report(inLludes DUP MS <br /> VuC�LUlU 1 s=,iarac-iatswo,tmgdays) MSD,atrequtred maybe <br /> Printed Name Pnnte N Printed Name Panted Name �Prnvi&Verbal Prrhm,n+ry Resulie charged as sample,) <br /> C�I�J We&vidcFAX Prri,vunaryRnuu, III Data Validation Report <br /> Firm ����� � Firm � Firm Finn Rry « � <br /> ��� �R� ,n Dale (imlud + <br /> � All Raw Data) <br /> l�I -2� � b J �� /d?„a RWQCB <br /> (MD /PQL I RACE#) <br /> Datellimm <br /> e Date/Time Daie� e Da1elTime Ls <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments Container Types Key <br /> 40 nil VOA I <br /> 125 ml LPE 2 <br /> Signature Signature <br /> SU()ml LPE 3 <br /> Pnnted Name Printed Name I Icier HDPE 4 <br /> 5W ml gla« 5 <br /> Finn Finn 1 trio g1 t4s 6 <br /> 2x6 sis ring 7 <br /> Q <br />