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TestAmerica San Francisco 7q � SY TestAmerica <br /> 1220 Quarry Lane Chain of Custody Record <br /> Pleasanton, CA 94566 !or 41 AV,ER'S VRCAMT-=%IA!7a S f3-` " <br /> Phone(925)484-1919 Fax(925)600-3002 <br /> Sampler: Lab PM: Carrier Tracking No(s): COC No <br /> Client Information (Sub Contract Lab) Sharma,Dimple 720-10050.1 <br /> Client Contact: Phone: E-Mail: Page: <br /> Shipping/Receiving dimple,sharma@testamericainc.com Page 1 of 1 <br /> Job#. <br /> Company: <br /> CompAnalytical Analysis Requested 720-30690-1 <br /> KIFFAddress: Due Date Requested: ,;Preservation Codes: <br /> 2795 Second Street,Suite 300, 1015/2010 A-HCL M-Hexane <br /> City: TAT Requested(days): .. B-NaOH N-None <br /> Davis C-Zn Acetate 0-AsNa02 <br /> £ D-Nitric Acid P-Na204S <br /> Stale,Zip: E-NaHSO4 O-Na2SC3 <br /> CA,95616 er,;. F-McOH R-Na2S2SO3 <br /> Phone: PO#' G-Amchlor S-H2SO4 <br /> C4 H-Ascorbic Acid T-TSP Dodecahydrate <br /> N I-Ice U-Acetone <br /> Email: <br /> WO#_ W), J-DI Water V-MCAA <br /> K-EDTA W-ph 4-5 <br /> Project Name: Project#: L-EDA Z-other(specify) <br /> Nestle-Ripon 72000256 = <br /> Site: SSOW#: Other: <br /> V <br /> Sample Matrix 9 <br /> Type (w-water. 0 <br /> NSample (C comp os etauo, <br /> LQ Sam le Identification-Client ID Lab ID Sample Date Time G rab aT Ti A-A1rN <br /> S ectal Instructions/Note <br /> N as <br /> INN M <br /> - . <br /> O z ye <br /> RC-1 (720-30690-1) 9/21/10 aciWater X I <br /> f <br /> P ifi <br /> ot, 7717 KIERNAN(720-30690-3) 9/21110 P4 Pacific Water X <br /> Ln1051 ROBERT(720-30690-4) 9/21/10 Water X7t <br /> Pacific <br /> if <br /> (n Pac <br /> s R. <br /> A, <br /> Possible Hazard Identification Sample Disposal(A fee may be assessed if samples are retained longer than 1 month) <br /> = Non-Hazard O Flammable Skin Irritant Poison B Unknown Radiological =Return To Client 0 Disposal By Lab Archive For Months <br /> Deliverable Requested: I, II, III, IV, Other(specify) Special Instructions/QC Requirements: <br /> Empty Kit Relinquishe by: Date: Time: <br /> Method of Shipment: <br /> Date/time: Company <br /> O Relinquished b Co Received by: <br /> L i✓• ll U lWn any <br /> � Relinquished by: <br /> Dat ime. Company Receiv b <br /> O <br /> Relinquished by: telTime. Co any R D DMilt O <br /> f i n O �r� l0' <br /> Custody Seals Intact: Custody Seal No.: Cooler Temperature(s)°C and Other Remarks LSD K+ /`f^ <br /> A Yes A No <br />