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M M M M M = * = M = = = = <br /> CHAIN OF CUSTODY 1 LABORATORY ANALYSIS REQUEST FORM <br /> Shaw Environmenad Purchase Order <br /> 1326 North Market Boulevard,Sacramento CA 95834 Lab CLS,Rancho Cordova <br /> Project Name Don Rodgers(Sp Sampling) Anal sis Requested <br /> Global ID- T0607700717 <br /> Project Number 120221/05000000 <br /> Report to Dan Wynne<Dan Wynne@shawgrp conn <br /> Company Shaw Environmental <br /> Address 1326 North Market Boulevard V w o <br /> Sacramento,CA 95834 u <br /> Dir Ph 416.5654184 1 FAX 16.56 -4356CU <br /> Qcc <br /> Sampler's Signature Z V3 Z REMARKS <br /> Sample LAB Sample 250 l PE 500 LPE Contamcr T es <br /> YP <br /> I D Date Time I D Matrix HNO3 NP Preservations <br /> MW-1R 5-1"'1 121A water 2 1 1 <br /> MW-3R water 2 1 1 <br /> MW-4RS I I kk1 water 2 1 1 <br /> MW-4RD 11141 water 2 1 1 <br /> VW-21) water 2 1 1 <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I Routine Report <br /> Sign �LtA� Signature Signature Signature 24 hr 49 hr 5 day A Report(includes DUP MS Uw" <br /> X Standard(-10.15 workmi days) MSD,as required,may be <br /> Pnn Name Printed Name Printed Name Printed Name Provide Wrhat Prck n wy Rcsu s charged as samples) <br />� FFirm <br /> FAX PraLaunary Results MRata Validation Report <br /> Firiii Pum Requested Repan Dau (includes All Raw Data) <br /> RWQCB <br /> Date/Time 3— Daterrime Datelrime DateJTime (MDL% <br /> (MDLs/PQLsI'TRACEq) <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments Container Types Key <br /> 40 ml VOA 1 <br /> Signature Si WCIS I..ab 125 ml LPE 2 <br /> Need EDD5 for GeoTracker. 3249 Fitzgerald Road 500 ml LPE 3 <br /> Printed Name d Send directly to- <susan waterman@shawgrp com] Rancho Cordova,Calif 95742 1 Ester HDPE 4 <br /> Fig Firinf� 916-638-7301/FX 638-4510 500 ml glass 5 <br /> 1/l S (/ `" Contact Ray Oslowski 1 liter glass 6 <br /> DatelPime DatPJTune - f Pis fax rcvd chain to Sheila @916-565 4356 2x6 sls ring 7 <br /> glass jar7 <br /> I <br />