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T20 Qua"rare Pleasanton Test medca <br /> 1220 Quarry Lane Chain of Custody Record <br /> Pleasanton, CA 94566 <br /> -Fir L rAPYu kh r41'IA[fNN F4T w, TrST'RC. <br /> Phone(925)484-1919 Fax(925)600-3002 <br /> Sampler Lab PM: er T COC No <br /> Client Information (Sub Contract Lob) Smith,Micah 720-38136.1 <br /> Client Contact Phone E-Mail- 5 O gin. Page: <br /> Shipping/Receiving micah.smlth@testamericainc.com California Page 1 of 2 <br /> Company Accreditation Required(see notey Job# <br /> TestAmenca Laboratories,Inc NELAP-California:State Program-California 720-85892-1 <br /> Address- Due Elate Requested_ Preservation Codes; <br /> 17461 Derian Ave, Suite 100, 412512018 Analysis Requested A-HCL M-Hexane <br /> City' TAT Requested(dayel: ,"'w 9-NaOH N-None <br /> Irvine 'h;,?,' C.Zn Acetate O-AsNa02 <br /> D-Nitric Acid P-Na204S <br /> State,Zip <br /> CA,92614-5817 E-NaHSO4 0-Na2SO3 <br /> P-MBOH R-Na2S203 <br /> Phone PO# [-AmchW 5-H2SO4 <br /> 949-261-1022(Tef) 949-260-3297(Fax) ;$$i'; H-Ascorb,C Aad T-TSP Dodecahydrate <br /> Email WO# <br /> k°` I-Ice U-Acetone <br /> J-Dl Water V-MCAA <br /> Project Name Protect#' J K-EDTA W-pH 4-5 <br /> Nestle-Ripon 72000256 a L-EDA Z-other(speofy) <br /> site SSOW#: n $ Other: <br /> » , <br /> to a <br /> Sample Matrix 7 <br /> Type (w Ww.s-.a a �i 2 <br /> Sample (C=comp, o..„rebw. g <br /> Sam to Identification-Client ID Lab ID Sample Date Time G- rab sr•Ti,i., #k F Special Instructions/Note: <br /> N Pmservadon Code: <br /> N 110 MANLEY(720-85892-1) 4112118 08'48 Water X 3 <br /> W <br /> 0 361 PARALLEL(720-85892-2) 4/12118 0900 Water X 3 <br /> ic <br /> RC-1(720-85892-3) 4112/18 09:35 Water X 2 <br /> Cn Pagifig <br /> 7971 KIERNAN(720-85892-4) 4112118 137 Water X 3 <br /> Pacifi7961 KIERNAN(720-85892-5) 4/12118 13'42 Water X 3 <br /> acific <br /> 1051 ROBERT(720-85892-6) 4112!18 09:57 Water X 3 <br /> Paoc <br /> 5724 HALL(720-85892-7) 4112118 13-23 Water X 3 <br /> acific <br /> TB-041218(720-85892-8) 4/12118 P8'i 7 Water X 2 <br /> RPS-1(720-85892-9) 4112118 09:16 Water X 3 <br /> Note Since Ieboratory accreditabons are subject to change,TestAmerica Laboratories,Inc places the ownership of method,analyte 8 accreditation compliance upon out subcontract laboratories.This sample shipment is forwarded under chainaf-custody, if the laboratory does not <br /> currently maintain accreditation in the State of Origin listed above for analyskS4ests1matrx being analyzed,the samples must be shipped back to the TestAmerice laboratory or other mstructlon5 will be provided. Any changes to accreditation status should be brought to TestAmence <br /> Laboratories,Inc attention rmmadlately If all requested accreditations are current to date,return the signed Chain of Custody attesting to said comphcance to TestAmerioa Laboratories,Inc <br /> Possible Hazard Identification Sample Disposal(A fee may be assessed if samples are retained longer than 1 month) <br /> Unconfirmed I ©Return To Client =D1sp+osal By Lab ©Archive For Months <br /> Deliverable Requested:t,fl,IIt,N,Other(specify) Primary Deliverable Rank.2 Special Instructions/QC Requirements: <br /> Empty Kit Relinquished by: I Date' ITime. I <br /> Method of Shipment <br /> Relmqushed by. '� Dat i e 1 Com r Received by DatelTkme Company <br /> Relinquished by DateMme, Company Recoved by. Data/Time Company <br /> Relknquishe y: Date/T;me- Company Received by Da Comf Jt i <br /> D Cut dy els Intact: Custody Seal No,: Cooler Tempe and Othe Remarks- {, f+”) <br /> Ye o Na J <br /> �oV Ver:09/20/2016 <br /> e � <br /> 1-11-1 n 1-1 <br />