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M M i i M m o m M M M MM m4r M <br /> CHAIN OF CUSTODY 1 LABORATORY ANALYSIS REQUEST FORM <br /> Shaw Ennronmenatl Purchase Order <br /> 1326 North Market Boulevard,Sacramento,CA 95834 Lab CLS,Rancho Cordova <br /> Project Name Don Rodgers Anal sis Requested <br /> GIoballD 70607700717 <br /> Project Number 120221/05000000 <br /> Report to Dan Wynne<Dan.Wynne@shawgrp.com> <br /> Company Shaw Environmental <br /> Address 1326 North Market Boulevard <br /> Sacramento,CA 95834 <br /> Dir Ph 916-565-4184 / 91 - 543 0 � <br /> Sampler's Signature Z <br /> REMARKS <br /> Sample LAB Sample 1 Container Types <br /> ID Dat Time ID Matrix HC1 Preservations <br /> MW-1R pt: v15 water 5 5 <br /> MW-2R <br /> MW-3R 3 water 5 5 <br /> MW4RS water 5 5 <br /> MW4RD V?qDwater 5 5 <br /> VW-ID water 5 5 <br /> VW-213 /0 S water 5 5 <br /> VW-3D b Z water 5 5 <br /> -4 0 water 5 5 <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> PREQU1RENMNTS X I Routine Report <br /> S Signature Signature Signature 24 hr 48 hr _5 day H Report(includes DUP,MS <br /> ; <br /> shrdud t—to is Workdays) MSD as required maybe <br /> Pn N Printed Name Pnnted Name Printed Name Pravde verbal Pmiff=ary Results charged as samples) <br /> Provide PAX Prehmuury Results Ili.Data Validation Report <br /> V Arm Firm Firm Requcsiw Repan nate (includes All Raw Data) <br /> �lRWQC13 <br /> Date retic 52-13164, FIN DatdTirne Date/Time Datemnie (MDis/PQ1s/tRACE#) <br /> RELINQL87WD BY RECEIVED BY Special Instructions/Comments Container Types Kay <br /> 40 m]VOA i <br /> Signature Si CLS Lab 125 ml LPE 2 <br /> Need EDDs for GeoTracker. 3249 Fitzgerald Road 500 nil L.PE 3 <br /> Printed Name a Send directly to, [susan waterman@shawgrp com> Rancho Cordova,Calif 95742 1 liter HDPE 4 <br /> 916-638-7301/Fx 638-4510 500 m]glass 5 <br /> Firm Finny Contact Ray Oslowski I liter glass 6 <br /> 2x6 s/s ring 7 <br /> Date/Time Dale/rtmffl PEs fax rcvd chain to Sheila @916-565-4354 glass3ar- 8 <br />