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i <br /> SAMPLE CHAIN-OF-CUSTODY ANALYSIS REQUEST �� � \ <br /> A s 1C- Shasta Analytical Laboratory <br /> 1872 W. Parkway Blvd. West Valley City, UT 84119 <br /> POSSIBLE HAZARDS: (801)973-6574 Fax(801)973-6584 <br /> Date N/f J Report To ANALYS"GUESTED Send unused <br /> Source of Samples J'F r Y Lu o t;- �vl.�N'F� Company �-A w R FEN I= 8 455 0 C . sample to: <br /> Sampler Name Address Lr�G ( 1�IA�KI'-I '' • lntsz �+ 0 <br /> Company )�r fes!?I JC, 01 0 L 00 �T Lab Destination: <br /> � v � <br /> Phone Carrier/Way Bill: <br /> Project No. 12. ' 1 Phone Z L� �r7G=' <br /> J C1 <br /> Collection Turn- Note 6 COMMENTS/CONDITIONS: <br /> ompo Note around Lab (Container type,container number,etc) <br /> LAB ID No. Client ID No. Date Time Type Depth site 4 lime Disposal <br /> J P- yr►5�� IO IL S S i)A <br /> ,Z EX-) 12- 1 103`1 S <br /> 3 Pz_ )r �-i 11as S K <br /> t)Write only one sample number in each space. 4)Preservation of sample. <br /> 2)Specify type of sample(s):Water(W),Solid(S),or indicate type. 5)Write each analyses requested across top.Place an"X"in <br /> 3)Mark each sample which should be composited in Laboratory as follows: Place an"A"in box for appropriate column to indicate type of analysis needed for <br /> each sample that should be composited into one sample;use sequential letter for additional groups. each sample. <br /> 6)Write address where unused sample should be sent or"X"Lab <br /> Disposal box if Lab should bill client for sample disposal. <br /> SAMPLE RELINQUISHED BY: SAMPLE RECEIVED BY: <br /> Print Name Signature Company Date Time Print Name Signature C mpany Date Time <br /> Lr,yrJ <br /> V. <br /> Logged in by: -—- -- -- - <br />