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�w w�■w ww w� ww ww w ww � ■w ww ww w� aw w� �w w► , <br /> CHAIN OF CUSTODY/LABORATOR ALYSIS REQUEST FORM <br /> Shaw Environmental Purchase Order <br /> 1326 North Market Blvd,Sacramento,Calif 95834 Lab <br /> Project Name N vg�s Anal sis Requested <br /> Project Number /,ZOa.2 <br /> Repoit to ��,� Vtirl„tinr t ti <br /> Company Shaw Environmental <br /> Address 1326 North Market Boulevard y <br /> c <br /> Sacramento,CA 95834 <br /> U <br /> Cell Ph (916)591-3161 FAX (916)565-4356 0 <br /> Sampler's Signature p <br /> REMARKS <br /> Sample LAB Sample Sleeve Container Types <br /> ID Date Time ID Matrix Ice Preservations <br /> - Soil - <br /> 2- <br /> )�I`I <br /> I <br /> P- I <br /> D� P--16 <br /> � - '�2,57 <br /> [[ 170 <br /> tJ P–'3y ����7 <br /> RELINQUISHED BY RECEIVED BY - RELINQUISHED BY RFCEIVE❑BY TURNAROUND REPORT REQUIREMENTS <br /> — REQUIREMENTS I Routine Report <br /> Signature at '� Signature Signature 24 hr 49 hr �5 day II Report(includes DUP,MS <br /> Standard MSD,as required,may be <br /> Printed Name Printed N e i Printed Name Printed Name Prowde Verbal Prelimmary Results charged as samples) <br /> Provide FAX Preliminary Results III Data Validation Report <br /> Firm Fi (I f A Firm Firm Requested Report Date (includes All Raw Data) <br /> / T"t RWQCB <br /> Datc/Time –4 Lf I Date/Time3-31-66 11 to Date/Time Date/Time (MDLs/PQL,P RACE#) <br /> RELINQUISHED BY RECEIVED BrY Special Instructions/Comments iContainer Types Key <br /> SIO ink VOA 1 <br /> Signature Signature � � '��� T f - 4 C".�,y� 250 m]LPE 2 <br /> 50 <br /> Printed Name Printed Name C yN� 1 liter HDPE 4 <br /> Ot O 5� – yi'$ 500 mi glass 5 <br /> Firm Firm 1 liter glass 6 <br /> 2x6 s/s ring 7 <br /> Date/Time Datelrime glass Jar 8 <br />