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LAB EQUIVA Ser es LLC Chain Of Custody Record �/ <br /> Lab idenWicatlon I ssary) Equiva Project Manager to be invoiced INCIOENT NUMBER(S&E ONLY) <br /> Address � <br /> ❑p SCIENCE&EN12NBER NG Karen Petryna <br /> C(Y Stolz Zip "—^� 9 $ 9 9 5 5 2 6 DATE /4"/0/ <br /> ❑TECHNICAL$2RViCES I SA>!or rOWNI M UR(TWI;RMT) <br /> [�cRIyT�Holrrory PAGE _z of <br /> WNW ULTANT WMPANY SITE ADDRESS(Strtrot and Chy) <br /> Blaine Tech Services <br /> A00RE3S 880 Victor Lodi <br /> 1680 Rogers Avenue PROJECT CONTACT(RFxpanlal CONSULTANT PROJECT NO <br /> CITYNic / <br /> San Jose,CA 85112 $AMPLLE NSAh7uEE(sI(PM) �G <br /> LAB USE ON1.Y' <br /> I Ti"1EPNONE FA% EMAIL. <br /> A <br /> 408-573-0555 408-573.7771 nsudano®blalnstech corn <br /> TURNAROUND TIME(BUSINESS GAYS) <br /> ❑10 DAYS ❑5 DAYS ❑72 HOURS [-148 HOURS ❑24 HOURS❑LESS THAN 24 HOURS REQUESTED ANALYSIS <br /> ❑LA RWQCB REPORT FORMAT ❑UST AGENCY a <br /> d Z <br /> GClMS MTBE CONFIRMATION HIGHEST HIGHEST per BORING ALL ,E d FIELD NOTES <br /> E , w <br /> SPECIAL INSTRUCTIONS OR NOTES TEMPERATURE ON RECEIPT Ca Ln m <br /> r,f p'k5`a I�t+At O"ty. M-11W,F-11110' IDX?C- b m a A ConiainerlPreservative <br /> r or PID Readings <br /> r4 0 <br /> Z ff 729A r AND r Dvill"Ge.4mv A""6 tWV4 Ae ro a or Laboratory Notes <br /> m n o <br /> db'L <br /> ifrtcai�� T8� rt AZPE 7ArlF a p o <br /> lap�si -/`l w <br /> I �J ,} 7 {^y N N N r m ` N <br /> �Q 6 /i�T N 0 N m q 1 ry <br /> l7 r% M p C <br /> O Y <br /> ZA8 SAMPLING x w w m c 0 w <br /> Wf Field Sample Identification MATRIX CONT a °�° W _ ' r W <br /> DATE TIME I- M 2 g p ua V <br /> w`•/ w G x x x 'XI I I I I I I I I I <br /> r-7— <br /> Ave I XXX I I )c I I X I I I _a z <br /> L✓'3 Doe -a <br /> N <br /> O <br /> r <br /> rn <br /> Ree b1'f5lgnaere) Recelvedby(Slgnalure} Dale Time <br /> XALOP <br /> ffi <br /> ellnwshed by ISrpnat rel Received by-{Signature <br /> Date Time u <br /> t <br /> a <br /> A <br /> Relinquished by(Spnalure) Received <br /> bl'(Signature) Date Trine a <br /> 02- 01 o / IHSS 0 <br /> DISTRIBUTION While vAth final report Green to File Yellow and Pink to ClOnt t0Y16=Rewsion <br />