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` CHAIN OF CUSTODY 1 LABORATY ANALYSIS REQUEST FORM Page f— <br /> 3 North Market Boulevard,Sacramento,CA 95834 ice Request No: PO Number: NIA <br /> EMCOfl (916)928.3300 FAX(916)928-3341 Lab: CAS <br /> Project Name:Teichert-Stockton Analysis Requested <br /> Project Number: 20F90-002.007,Task 001 <br /> Project Manager: Matt Turner <br /> Company: EMCON-Pinnacle oNo <br /> Address: 3939 Cambridge Road,Suite 202 A <br /> Cameron Park, CA 95682 U <br /> Phone: (530) 676-6881 c <br /> FAX: (530)676-6885 o <br /> Sampler's Signature: _ ' x <br /> z IREMARKS <br /> Sample LAB Sample I Container Types <br /> I.D. Date Time I.D. Matrix HCI Preservations <br /> MW-9 water 3 3 <br /> MW-10 4, water 3 3 <br /> MW-11 3 ! 11SZ water 3 3 <br /> MW-12 water 3 1 3 <br /> MW-13 3 7 C 4( water 3 3 <br /> MW-14 water 3 3 <br /> 3 <br /> N=RELINQUISHP�k <br /> EV`BY R EIVEY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I. Routine Report <br /> Signature [ _ {, ature Signature Signature 2a la 49 br s day 11. Report(includes DUP,MS <br /> b'�` "'� eM Ac X sundara-(-10-15 Wor><m&nays) MSI),as required,may be <br /> Printed Name Printed <br /> �tm <br /> Name Printed Nae Printed Name Provide Verbal Prelinvury Results charged as samples) <br /> `�-^�— 4 " '" Provide FAX Preliminary Res" Ill.Data Validation Report � <br /> Firm Fi Firm Fimt Requested Report Date: (includes All Raw Data) <br /> t) C3-1) RWQCB <br /> Date rune Date/time Date/time Date rime (MDL,/PQL,/!RACE#) <br /> RELINQUISHED ISY RECEIVED BY Special InstrurlionslComments: Container Types Key; <br /> 1 �q 40 ml VOA: I <br /> Signature Signature �.t.�2 0 �1 0 / Columbia Analytical 250 ml LPE: 2 <br /> 3334 Victor Court 500 ml LPE: 3 <br /> Printed Name Printed Name Z Santa Clara,Ca 1 liter HDPE: 4 <br /> 408-748.9700 500 ml glass: 5 <br /> Firm Firm ��� �J I literglass: 6 <br /> 2z6 sls ring: 7 <br /> Date/fimc Da[e/I ime glass jar. 8 <br />