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AColumbia CHAIN OF CUSTODY/LABORATORY ANALYSIS REPORT FORM <br /> Analytical <br /> Services'"` 3334 Victor Court•Santa Clara,CA 95054 <br /> (408)748-9700•FAX(408)748-9860 BERVICE REQUEST NO. J ( P.O.# _PAGE l OF <br /> PROJECT NAME Ll 0 W . ►-w4K/ WaM # 5 44 4) 2ANALYSIS REQUESTED <br /> PRESERVATIVE HCI HCI HCI NP NP NP HCI HNO NP H S0, W011 <br /> PROJECT MGR. 1co <br /> U) �� �� ? U <br /> �� <br /> COMPANY Yl' �1( ' z U� o o r � �o Q 2� <br /> Uj <br /> ADDRESS CL <br /> z m o v ) n� m r a �, ~� <br /> m`o �O ° Q' Q <br /> o (p N k\ Ui v, <br /> P NE c,"�N Q`N ���� r O U o r v �° '�� o v N <br /> LL <br /> 0 mr` o� mm � pr a `b <br /> O O)o a m � � Qno `mac �I 8 � (j0 pQ <br /> Mr p`v _Q,1, (D � O -3 C o �T S a � O Q I I <br /> SAMPLER'S SIGNATURE w o C�CU coy r v, aQ, a� c U O �J <br /> SAMPLE B SAMPLE o o°� 2Z ZZU r co <br /> �a Q2 a m G��O 1=,? <br /> 1.D. DATE TIME MATRIX z �°� a Qr m 2 Q° ~�O ���� QQ =20 U� 1� REMARKS <br /> SP— b2� s M12- So; I K d: I <br /> 3 <br /> X_ <br /> s p — 5 ,�,� q x c <br /> SP RA <br /> SP <br /> RELIVCtSFIED Y: REC V b BY: RELINQUISHED BY: RECEIVED BY: TURNAROUND REQUIREMENTS REPORT REQUIREMENTS <br /> I.Routine Report <br /> Sign�re�l� ,ty��` �� Signature Signature _ 1 day _2 day_3 day II.Report(includes MS. <br /> —j5 a�Other MSD,as required,may be <br /> Printed Name Printed.Name Printed Name Printed Name ` J charged as samples) <br /> �AFg P.5� ;S' Standard(10 wor ing days) _ III.Data Validation Report <br /> Firm Firm Firm Firm (includes All Raw Data) <br /> Results Due _ IdDLs/POLsITrace# <br /> Dateffi e Date Mme Date/Time Date/Time Electronic Data Deliverables <br /> RELINQUISHED BY: RECEIVED BY: SAMPLE RECEIPT: Condition Custody Seals <br /> SPECIAL INSTRUCTIONS/COMMENTS: <br /> Signature Signature Circle which metals are to be analyzed: <br /> Printed Name Printed Name Metals: Al 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 Q yY <br /> Firm Firm V�t6l�f— <br /> Ur V U <br /> Date/Time Date/Time <br /> �t,S I <br /> Shipped Via/Trackin # 9e: <br /> ✓e�Id D Stora <br /> *Will sample results be used in connection with drinkimn water icgithtinns? 1-1 Y—i I hto Mr ,,,,,j mii,,t so indicate by writing"PIN"for each such sat nlo <br />