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CHAIN OF CUSTODY 1 LABORATIf ANALYSIS REQUEST FORM Page o_ <br /> North Market Boulevard,Sacramento,CA 95834 ��fce Request No: PQ Number: N/A <br /> smico 1 (916)928-3300 FAX (916)928-3341 Lab: CAS <br /> Project Name:Teichert-Stockton Anal sis R uested " <br /> Project Number: 20F90-002.007,Task 001 <br /> Project Manager: Matt Turner o <br /> Company: EMCON-Pinnacle <br /> Address: 3939 Cambridge Road,Suite 202 � <br /> Cameron Park,CA 95682 U <br /> Phone; (530) 676-6881 0 to <br /> FAX: (530) 676-6885 , L� -a' 1...-� O <br /> Sampler's Signature: <br /> z *[ REMARKS 4 <br /> w <br /> Sample Sample I Container Types j <br /> I.D. Date Time I.D. Matrix HCI Preservations <br /> MW-9 311a I 120's water 3 3 <br /> MW-10 t zme Jwater 3 3 <br /> MW-11 BON 1052 water 3 3 <br /> MW-12 T/g l.5i? water 3 3 <br /> j MW-13 (W water 3 3 <br /> MW-14 IV ['551 water 3 3 <br /> Mki — 3111 1(6q wat.c. <br /> MAJ <br /> RELINQUISHER BY t RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> L � REQUIREMENTS X I. Routine Repots <br /> Signature q Signature Signature Signature 24 Ir aslff 5 day It. Report(includes DUP.MS <br /> :Do -A" <br /> IrIc 'i X sra<mard(-10-15 workmg days) MSD,as required,may be <br /> Printed Name Printed Name Printed Name Printed Name Pro�idr Verbal Prelan6ury Results charged as samples) <br /> � 1 P[avi&FAX Preliminary Results III.Data Validation Report <br /> FirmFirm Fimt Firm Requested Report Dau: <br /> (includes All Raw Data) <br /> RWQCB <br /> Date/Irma/Z: i�j. Datelrime Datefrime Date�me (MDLsIPQLs/IRACEt1) <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments: Contamer Types Key: <br /> 40 ml VOA: I <br /> Signature Signature Columbia Analytical 250 ml LPE: 2 <br /> 3334 Victor Court 500 ml LPE: 3 <br /> Printed Name Printed Name Santa Clara,Ca I liter HDPE: 4 <br /> 408-748-9700 500 ml glass: 5 <br /> Funs Firm I liter glass: 6 <br /> 2x6 sis ring: 7 <br /> Date/rime Date/Fime Iglass jar. 8 <br />