Laserfiche WebLink
fCHAIN OF CUSTODY/LABORATORY ANALYSIS REPORT FORM <br /> Anolyticol <br /> 3334 Victor Court Santa Clara,CA 95054 ' <br /> Services s D Z2 'Z 2 <br /> Oe,.,r����,H,c�..,,..>c.,,��r*��.- (408)748-9700-FAX(408)748-9 60 ggg�� SERVICE REQUEST NO. _ _ _ P.O.# PAGE_ OF <br /> PROJECT NAME��D •L-I +C �# SAP'# I S ANALYSIS REQUESTED <br /> PRESERVATIVE HCI HCI HCI NP NP NP HCI HNO, NP H S0, NaOH <br /> PROJECT MGR. ( r n N U <br /> cv ~ O <br /> COMPANY CIa�YV`�'lV�a� t/ - w ~a <br /> Q <br /> ADDRESS <br /> o <br /> rO o N <uxk U <br /> PHONE m_"v Q N to n O Udo r m �° � o nl <br /> LL c . o ¢��- D r m m o <br /> FAX O pmo a m a" Qno c a .� V= O a t l (( <br /> a O N ro r U(D p m v y v� o • OO a �( <br /> SAMPLER'S SIGNATURE w 03 a,w o � c r °i a s co VVV <br /> SAMPLE LAB SAMPLE o Q�2 aim ro„� ti aQ m v o ZOO 2O �� �� REMARKS <br /> 1.D. DATE TIME I.D. MATRIX z ,cow z� tia �Z mco aQ gyp' ~ QQ 2Z U <br /> ` l 6'- ' o j X 7 d • 1 CA <br /> S - �5 Oro <br /> SP- 11L0 As <br /> sP t8 ER <br /> ELI ED BY: RECEIVED BY: RELINQUISHED BY: RECEIVED BY: TURNAROUND REQUIREMENTS REPORT REQUIREMENTS <br /> _44 I.Routine Report <br /> L <br /> �f,s Signature Signature Signature 1 day 2 day 3 day ll.Report(includes MS. <br /> Aday —Other MSD,as required,may be <br /> Printed Nam Printed Name Printed Name Printed Name charged as samples) <br /> Standard(10 v rking days) _ III.Data Validation Report <br /> Fir— Firm <br /> _ ��p� Firm Firm Firm (includes All Raw Data) <br /> _ Results Due h1DLs/POLs/Trace I <br /> Datel I ime Date[Time OatelTime Date/Time <br /> Electronic Data Deliverables <br /> RELINQUISHED BY: 4REC� E BY: SAMPLE RECEIPT: Condition Custody Seals <br /> SPECIAL INSTRUCTIONS/COMMENTS: <br /> Signature Si n t re / Circle which metals are to be analyzed: <br /> Printed Name Printed am Metals: At Sb Ba Be B Cd Ca Cr Co Cu Fe Mg Mn Mo Ni K Ag Na Sn V Zn <br /> Firm Firm As Pb Se T�/ Hg <br /> Y .� /) / <br /> DatelTime Dat /I ime Gt�✓� / -7-12-4 /0' <br /> 77 <br /> Shipped Via/Trackin # 5 r`1�/`(eJr (p ,� 5 f Storage: <br /> 'Will sample results be used in connection with drinking water regulations? 1-1 Yes 1-1 No If yes,you must so indicate by writing"DW"for each such sample. <br />