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� r r r r rr � r � r� r rir r r r�r rrrw r <br /> d <br /> CHAIN OF CUSTODY I LABORATORY ANALYSIS REQUEST FORM <br /> Shaw Environment Purchase Order <br /> 1326 North Market Boulevard Sacramento,CA 95834 lab CLS,Rancho Cordova <br /> Project Name Don Rodgers Anal sts Requested <br /> Global ID• T0607700717 <br /> Project Number 120221/05000000 <br /> Report to Dan Wynne<Dan.Wynne@shawgrp coria <br /> Company Shaw Environmental N <br /> Address 1326 North Market Boulevard U <br /> Sacramento,CA 95834 <br /> Dir Ph 916-565.4184 1 F 916-5654y6 <br /> Sampler s Signaturez I REMARKS <br /> Sample LABESarnple i Container Types <br /> I D Date Time ID- HCI Preservations <br /> MW-1R 6-7,1,0'01464 5 5 <br /> MW-2R <br /> MW-3R 10`I`t water 5 5 <br /> MW-4RS 12- water 5 5 <br /> MW-4RD 5Z- water 5 5 <br /> VW-1D 1 water 5 5 <br /> VW-21) water 5 5 <br /> water <br /> VW-4 Qty water 5 5 <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X 1 Routine Report <br /> 5tgn re Signature Signature Signature u h< 49hr _5 day E Report(includes DUP.MS <br /> X Sntdam(-10-15.Adq dayr) MSD,as required maybe <br /> pro Nam Punted Name Pume Printed NaPnnted Nam Rodda VerbairrasndoMTtwuhc charged as samples) <br /> PMA&FAX Pi WUWY Rowla 111.Data Validation Report <br /> p;�� 1 �,�� Firm Firm Firm aegoesud tteeaon Uetc (includes All Raw Data) <br /> H`rv✓ G RWQCB <br /> Daterriine DamrFirne DaWrime Date)Time (Nm1a1PQLsfCRAC ) <br /> RELINQUISHED BY RECEY V ED BY Speclal Instructions/Comrnents Container Types Key <br /> 40 ml VOA t <br /> 5ignatiire Sign CLS Lab 125 ml LPE 2 <br /> I&k Need EDDs for GeoTracker. 3249 Fitzgerald Road 500 ml LPE. 3 <br /> Printed Name Pn tune send directly to- <susan.waterman@shawgrp com> Rancho Cordova,Calif 95742 1 liter HDPE 4 <br /> 916-638-7301/lix 638-4510 S00 ml glass 5 <br /> Finn Firm Contact Ray Oslowski 1 liter glass 6 <br /> 2x6 sts ring 7 <br /> glassjar 8 <br /> Datc,Tiitns Datime Pls fax rcvd chain to Sheila @916-565-4356 <br />