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TestAmerica San Francisco <br /> 1220 Quarry Lane Chain of CustodyRecord ' <br /> PleaA&aorr,—,!A 94566 <br /> Phone(925)484-1919 Fax(925)6OC-3002 <br /> Samples Lab PM: Carrier Tracking Ne(s)': COC No: <br /> Client Information Sub Contract Lab) Sharma, Dimple 720-10090.1 <br /> Client Contact: Phone: E-Mal: Page: <br /> Shipping/Receiving dimple.sherrna@testamericainc.com Page 1 of 1 <br /> Company: Job M <br /> TestAmerica Laboratories, Inc. Anal sis Requested 720-30781-1 <br /> Address: Due Date Requested: Preservation Codes: <br /> 4101 Shuffel Street NW, 10/8/2010 <br /> City: TAT Requested(daysi: A-HCL M-HexaneB-Nal N-None <br /> North Canton C-Zn Acetate O-AsNaC2 <br /> State,Zip, m D-Nitric Acid P-Na204S <br /> OH,44720 E-NaHSO4 0-Na2SC3 <br /> M <br /> Phone. PO# F-MBOH R-NaMSC3 <br /> 330-497-9396(Tei) 330497-0772(Fax) G-Amchlor S-H2SC4 <br /> H-Ascorbic Acid T-TSP Dodeciehydrate <br /> EmaiC WO#: = I-Ice U-Acetone <br /> m J J-DI Water V-MCAA <br /> Project Name' Project N: m K-EDTA W-ph 4-5 <br /> Nestle-Ripon72000256 3 L-EDA Z-other(specify) <br /> Site: SSOW#- <br /> t Other: <br /> H <br /> U <br /> Sample Matrix <br /> type <br /> S...lid. i U <br /> Sample (C=comp, 0-wasw'll' ap <br /> Sam le Identification-Client ID Lab ID Sample Date Time G= rab) BT-Ti...,A-Air Ul Special Instructions/Note: <br /> fy <br /> BERM Elm M IN NO <br /> 802 VERA INF(720-30781-1) 9127110 P ifi oriWater X <br /> fi <br /> ^t r <br /> 27-10 <br /> ti <br /> 3 8 <br /> Possible Hazard Identification Sample Disposal(A fee may be assessed if samples are retained longer than 1 month) <br /> =Non-Hazard =Flammable Skin Irritant © Poison B Unknown © Radiological Retum To Client Disposal a Lab Archive For.Months <br /> Deliverable Requested:t, ,III, IV,Other(specify) Special Instructions=Requirements: <br /> i <br /> Empty Kit Relinquished : Date: Time: Method or Shipment: <br /> Relinquished by i Date !� q { Ca Received by: Detelrime: Company <br /> �%�7 9-.24-(Q <br /> Relinquished by: DatelTi Company Received by: DatefTime: Company <br /> Relinquished by: Daterrime: Company Received by: DatelTime: Company <br /> Cuskody Seals]ntGi L'ush3dy Seal�10 GaNeetaT pBrature(s}C a �rkg <br /> nd ether Rei <br />