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TestAmerica San Francisco 6S207 <br /> i1220 Quarry lane Test m�ca <br /> 1 r Chain of Custody Record <br /> Pleasanton, CA 94566 <br /> Phone(925)484-1919 Fax(925)600-3002 a�r� L+ ura tw tuvrursrersr vra`x€srsaae <br /> Sampler: Lab PM: Camer Tracking No(s): CDC No: <br /> Client Information Sub Contract Lab Sharma,Dimple 720-4785.1 <br /> Client Contact: Phone: E-Mail: Page: <br /> Shipping/Receiving dimple.sharma@testamericainc.com Page 1 of 1 <br /> Company: Jab#' <br /> KIFF Analytical Analysis Requested 720-19209-1 <br /> Address: Due Date Requested: Preservation Codes: <br /> 2795 Second Street,Suite 30Q 5/1/2009 <br /> A-HCL M-Hexane <br /> City: TAT Requested(days): B-NaOH N-None <br /> Davis C-Zn Acetale O-AsNaO2 <br /> State,Z'ip: D-Nitric Acid P-Na2045 <br /> CA,95616 F-NaHSO4 0-Na2S03 <br /> F-McOH R-Na2S2S03 <br /> Phone: PO#: <br /> G-Amchlor 5-H2SO4 <br /> �I H-Ascorbic Acid T-TSP Dodecahydmte <br /> a <br /> Email: WO#: I-Ice U-Acetone <br /> n. J-DI Water V-MCAA <br /> 9 K-EDTA W-ph 4-5 <br /> Project Name: Project#: U t--FDA Z-other(Specily) <br /> Nestle-Ripon 72000256 o <br /> sne: ssow#: _ <br /> Other: <br /> v <br /> Sample Matrix <br /> Tye (w.werer, 0 <br /> 1`0Sample (C=camp, o-S,d..a m <br /> fL Sam le Identification-Client ID Lab ID Sample Date Time G= rob ar.ra�. r M S tial Instructions/Note: <br /> ZI <br /> IN FA <br /> W MW-3(720-19209-10) 4117109 10:24 Water X 70�(nO MW-7(720-19209-11) 4117109 9:42 Water X 1-hW MW-10(720-19209-12) 4117109 10:13 Water X to 7 IT7 MW-13(720-19209-13) 4117109 8:49 Water X <br /> - _'t-o <br /> MW-14(720-19209-14) 4117109 10:00 Water X Q <br /> MW-18(720-19209-15) 4117109 8:58 Water X <br /> TB-041709(720-19209-16) 4/17109 10:45 Water X <br /> O Sr er .1 # l -. <br /> at <br /> 6 C tat res nt 1 <br /> Possible Hazard identification Sample Disposal(A fee may be assessed it samples are retained longer than f month) <br /> 1=1 Non-Hazard =Flammable ©Skin Irritant Poison B = Unknown Radio! ical M Return To Client =Disposal By Lab Archive For Months <br /> Deliverable Requested:I,II,III,IV,Other(specify) Special Instructions/OC Requirements: <br /> I ,N <br /> Empty Kit Relinquis by: Date: TimMethod of Shipment, <br /> d4�b�rj Lam, <br /> Relinquished by: Date me: j Company Received by. Date/Time: crompany <br /> t12 A <br /> Helinquished by: D teRme Company Received by: Date/Time: Company <br /> Relinquished by: c ed DateMme: Company by' <br /> CW1"!FF <br /> 1 <br /> Custody Seals Intact: Custody Seal No.: 6oaier7emperatu a s)°C and Mar Remarks: <br /> A Yes A No <br />