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°+y STATE OF CALIFORNIA—ENVIRONMENTAL PROTECTION AGENCY <br /> REGIONAL WATER QUALITY CONTROL BOARD <br /> CENTRAL VALLEY REGION (�FUI <br /> 3443 ROUTIER ROAD,SUITE A • SACRAMENTO,CA 95827-3098 OF <br /> PHONE: (916)255-3000 • FAX: (916)255-3015 <br /> PROGRAM PCA PROJECT NAME <br /> La FIELD <br /> Z� j v Ch e v vo ANALYSIS REQUIRED CONDITIONS <br /> ,��' 1. G• 'C <br /> SAM PLF.I�>(Signature) (TEMP..WINO,ETC <br /> .) <br /> PRINT NAME U) <br /> / ' G_ ft�l w <br /> a� � � > <br /> S A M P L E CONTAINER MATRIX a- III <br /> m W <br /> O Qi: w <br /> o <br /> IDENTIFICATION LOCATION DATE TIME TYPENO. WASTE- SOIL/ U <br /> WATER SLUDGE 0 a <br /> WATER lj <br /> LAB NO. <br /> a3-L -37 <br /> SPECIAL INSTRUCTIONS/SUSPECTED CONSTITUENTS <br /> u <br /> R LINQUISHED BY (Signature) DATE/TIME RECEIVED B (Signature) RELINQUISHEDature BY Si n <br /> ) DATE/TIME JHECEIVEDBY (Signature) <br />