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s20 Q meLane Pleasanton TestAmerica <br /> Pleasanton, CA 94566 Chain of Custody Record II �IIININMIaNN IhNI��IN llNlllNNll <br /> THF LFAUFR IN 1=yYIR0MNFNTA1.TF 9TIN6 <br /> Phone(925)484-1919 Fax(925)600-3002 <br /> Sampler Lab PM Carner Tracking No(s) COC No <br /> Client Information (Sub Contract Lab) Smith,Micah 720-38654.1 <br /> Cliant Contact Phone E-Mail State of Origin- Page <br /> Shipping/Receiving micah,smith(otestamericalne.com California Page 1 of 1 <br /> Com an Accreditation Required(See note) Job# <br /> P Y <br /> TestAmerica Laboratories,Inc NELAP-California;State Program-California 720-86806-1 <br /> Address- Due Date Requested: Preservation Codes: <br /> 17461 Derian Ave, Suite 100, 6/18/2018 Analysis Requested A-HCL M-Hexane <br /> City TAT Requested(days): 8-NaOH N-No <br /> Irvine "•_ C-Zr Acetate 0-A.Na02 <br /> State,Zip O-Nitric Acid P-Na204S <br /> CA,92614-5817 m E-NaHSO4 O-Na25O3 <br /> Phone pO g } F-McOH R-Na2S203 <br /> G-Amch€or S-H2SO4 <br /> 949-261-1022(Tel) 949-260-3297(Fax) a H-Ascorbic Acid T-TSP Dodecahydrate <br /> Email WO# �_ , T-Ice U-Acetone <br /> o J-01 Water V-MCAA <br /> Protect Name Project# K-EDTA W-pH 4-5 <br /> 3 L-EDA Z-other(specify) <br /> Nestle-Ripon 72000256 <br /> Site $SOW# Other: <br /> Sample Matrix i <br /> Type <br /> Sample (Cmcomp, o resmolr a l; ; <br /> Sam le Identification-Client iD Lab ID Sample Date Time G= rob aT=T sees,A=Arc Special Instructions/Note: <br /> TB 06051 { ) 09cif2 '' <br /> 8 720-86806-1 615118 0 Water X ' <br /> N <br /> Q 7501 KIERNAN 2008 EFF(720-86806-2) 615118 09:20 Water X $ <br /> N 7501 KIERNAN 2008 MID(720-86806-3) 615118 09:23 Water X d 2 <br /> 00 Pacific <br /> 7501 KIERNAN 2008 INF(720-86806-4) 615118 09-26 Water X "3 <br /> Pacific <br /> 5725 HALL 2009 EFF{720-868065) 615118 09-42 Water X 3, <br /> Pacific <br /> 5725 HALL 2009 MID(720-868065) 615118 09:46 Water X 3: <br /> aCifiC <br /> 5725 HALL 2009 INF(720-86806-7) 6!5!18 ' f Water X ` <br /> Pacific <br /> 1051 ROBERT(720-86806-8) 615/18 10.f Water <br /> Pa if <br /> r <br /> Note Since laboratory accreditabons are sub{ed to change,T--Amens Laboratories,Inc places the ownership of method,analyte&accreditation compllance upon out subcontract laboratones Th¢S sample shipmenLts forwarded under chamof<:ustody If the laboratory does not <br /> currently maintain accreddation in the State of Origin listed above for analystslte5lsfmatax being analyzed,the samples must be shipped back to the TestAmenca laboratoryor other mstructions will be provided Any changes to accreddation status should be brought to TestAmenea <br /> Laboratories,tric attention immediately If ali requested a—ditaaons are current to date,return the signed Chain of Custody attesting to said cnmplrcance to TestAmmice Laboratories,Inc <br /> Possible Hazard identificatlon Sample Disposal(A fee may be assessed if samples are retained longer than 1 month) <br /> Unconfirmed ©Return To Client Disposal By Lab Archive For Months <br /> Deliverable Requested:I,11,Ili,IV,Other(specify) Primary Deliverable Rank'2 Special tnstrudionsiOC Requirements: <br /> Empty Kit Relinquished by: Date: Time: Method of Shipment <br /> JRehngvisheDaterrlme Company Received by Date/Time Company <br /> Reorshed by DatelTime Comp ny Received by DateMme Company <br /> O Reilnquished by DetelTlmo Company Received by Datea e' Company <br /> N <br /> CD Custody Seals Intact CuStedy Seal No.: ter Temperature(s)°C and Other Remarks <br /> ,Yes A No <br /> Oo -- <br /> Ver,09/2©/2016 <br /> n <br />