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fu <br /> L�CWmbw Opt CHAIN OF CUSTODY/LABORATORY ANALYSIS REPORT FORM. ; <br /> A AnaytKa <br /> SIYYN:li M SERVICE REQUEST NO. V " I I 1 P.O.# PAGE OF I <br /> 3334 Victor Court•Santa Clara CA 95054. 408 437.--2400•FAX 408 437-9356 r <br /> PROJECT NAME CroSS r0 4 S C-P tit PCA `>�'Q ANALYSIS REQUESTED <br /> PRESERVATIVE HCI HCI HIM NP NP NP HCI HCI HNO NP SO H2SO4 11SO NaOH <br /> PROJECT MGR. W /1.(ta.l�, V "t �5tcekS ,p <br /> COMPANY Gra `rd ao<c50-n I f A h K• e'dop -Fvc 00 <br /> to m co, 2 <br /> / n Z �c �0 y D y /U tiY <br /> ADDRESS 1 Q Q Q L0. n 5f 51 20 l N m o U m o <br /> SG Q C 14Lrq c r9rQSp NE 3L7 ' 0110 p oho Qa ~�N S OVo my D Uo Um <br /> N CO` ti <br /> 3L7 0119 pU0 Q .o <br /> SAMPLER'S SIGNATURE w y cmo v c M O <br /> 2vu <br /> SAMPLE LAB SAMPLE oU � aZh QZ� mU io Q4 m °'m2r _Z o U o`m REMARKS <br /> 1.D. DATE TIME .D. MATRIX Z ~/-p ti U <br /> j�wD — I s/Sy �3 �s w� fer <br /> RLI I Y: REICgEIIV+EDD'BY: RELINQUISHED BY: RECEIVED BY: TURNAROUND REQUIREMENTS REPT REQUIREMENTS <br /> I�T7 "j ` """-""'•"` ✓1 da 2 da 3 da •/I.RoWne Report <br /> �gnatp Sig to Signature Signature y — y y _ II.RePon(includes MS. <br /> /if/.r//B/YJ '�f S' ✓e 5 da Other MSD,as required,may be <br /> P��1Pted Nam%�/j Prif�ted ame Printed Name Printed Name y charged as samples) <br /> (O-r'O(/, _ Standard(10 working days) — III.Data Validation Report <br /> 3 S $ Fir Firm Firm (includes All Raw Data) <br /> ,,F& F t� I Results Due S b R MDLsIPOLs?raceI <br /> DatelTime Date im Date/Time Date/Time Electronic Data Deliverables <br /> RELINQUISHED BY: RECEIVED BY: SAMPLE RECEIPT: Condition Custody Seals <br /> SPECIAL INSTRUCTIONS/COMMENTS: 2-Lt kr WA <br /> Signature Signature Circle which metals are to be analyzed: <br /> Printed Name Printed Name Metals: At Sb Ba Be B Cd Ca Cr Co Cu Fe Mg Mn Mo Ni K Ag Na Sn V Zn <br /> As Pb Se TI Hg <br /> Firm Firm <br /> 121 �3 <br /> Date/Time Date/Time 2 <br /> Shipped Via/Tracking# Storage: 9-% <br /> DISTRIBUTION: WHITE-return to originator; YELLOW-lab; PINK-retained by originator 400-5 <br />