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TestAmerica San Francisco 7 W�4 !e— S �' M <br /> t erica <br /> 1220 Quarry Lane <br /> Pleasanton, CA 94566 Chain of CustodyRecord <br /> Plea <br /> Phone(925)484-1919 Fax(925)600-3002 <br /> Sampler: Lab PM: Carrier Tracking Noisy COC No: <br /> Client Information (Sub Contract Lab) Sharma,Dimple 720-10173.1 <br /> Client Contact: Phone: E-Mail: Page: <br /> Shipping/Receiving dimple.sharma@testamericainc.com Page 1 of 1 <br /> Company: Job#: <br /> KIFF Analytical Analysis Requested 720-30962-1 <br /> Address: Due Date Requested: - Preservation Codes: <br /> 2795 Second Street,Suite 300, 10/18/2010 A-HCL M-Hexane <br /> City: TAT Requested(days): ,j B-NaOH N-None <br /> Davis )`` C-Zn Acetate 0-AsNa02 <br /> State,Zip: D-Nitric Acid P-Na204S <br /> CA,95616 E-NaHSO4 Q-Na2SO3 <br /> Phone: PO#: <br /> F-McOH R-Na2S2SO3 <br /> Cl! G-Amchlor S-H2SO4 <br /> v H-Ascorbic Acid T-TSP Dodecahydrate <br /> Email: WO#: N I-Ice U-Acetone <br /> _ J-DI Water V-MCAA <br /> Project Name: Project* w K-EDTA W-ph 4-5 <br /> Nestle-Ripon72000256 O L-EDA Z-other(specify) <br /> Site. SSOW#: Other: <br /> Sample Matrix ). <br /> Type (w.wner, p 4 <br /> n1 Sample (C=Comp ossalon, m <br /> PN Sample Identification-Client ID Lab ID Sample Date Time G=grab) aT TI..,A-An) <br /> Special Instructions/Note: <br /> N4­1RER <br /> „ <br /> 7501 KIERNAN 2008 EFF(720-30962-1) 10/5110 09'02 Water X <br /> Pacc 0/ <br /> 0 7501 KIERNAN 2008 MID(720-30962-2) 1015/10 09:06 Water X Z <br /> I-h Pacific <br /> Fr <br /> 7501 KIERNAN 2008 INF(720-30962-3) 1015/10 P9'If Water X ?� <br /> 802 VERA EFF(720-30962-7) 1015/10 11:18 Water X ? <br /> Pacific <br /> 802 VERA MID(720-30962-8) 10/5/10 11.21 Water X <br /> Pacific <br /> 802 VERA INF(720-30962-9) 10/5/10 11:24 Water X <br /> Pacific <br /> TB-100510(720-30962-10) 10/5/10 08'25 Water X <br /> Pacific <br /> Possible Hazard Identification Sample Disposal(A fee may be assessed if samples are retained longer than 1 month) <br /> 0 Non-Hazard O Flammable Skin Irritant Poison B Unknown Radiological O Return To Client O Disposal By Lab Archive For Months <br /> Deliverable Requested: I,II,III,IV,Other(specify) Special Instructions/QC Requirements: <br /> v <br /> to Empty Kit Relinquished by: Date: Time: Method of shipment. <br /> (D <br /> Relinquished by. Daterrime: Company Received by: Daterrime. Company <br /> Relinquished by. ime: Company -Received by: Daterrime: Company <br /> Relinquished by: DateMme: Company P Y Refav y: ` n Date 7ime;D n�Z CMR Y <br /> Custody Seals Intact: Custody Seal No.: Cooler Temperature(s)°C and Other Remarks: <br /> A Yes o No <br />