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CHAIN OF CUSTODY/ LABORA RY ANALYSIS REQUEST FORM <br /> IT/EMCON - 1433 North Market Boulevard,Sacramento, CA 95834 Service Request No Purchase Order <br /> (916)928-3300 FAX(916)928-3341 Lab SEQUOIA <br /> Project Name IRC-Stockton Analysts Requested <br /> Project Number IT#792759122605-101.003 <br /> Project Manager Mark Capps o <br /> Company 1T/EMCON CD <br /> Address 3939 Cambridge Road,Suite 220 in <br /> Cameron Park,CA 9682 0 ovo <br /> Phone (530)676-6881 U X o <br /> FAX (530)676-6885 <br /> 00 <br /> Sampler's Signature pj <br /> C7 <br /> x <br /> REMARKS <br /> Sample Sample 1 Container Types <br /> ID ate Time I D Matrix Hcl Preservations <br /> MW-1 '-qwater 3 3 <br /> MW-2 t 3 Da water 3 3 <br /> I <br /> #RELIIY RECEIVED BY REI INQUISHED BYRECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X I Routine Report <br /> Signature Signature Signature 24 hr 4s hi 3 day II Report(includes DUP,MS <br /> X <br /> PnnlcaStandard(-la is working days) MSD,as required,may be <br /> m� Printed NamePrinted Name Printed Name Provide Verbal PITIMEarr Results <br /> / charged as samples) <br /> Provide FAX Prelrm,nary Results III Data Validation Report <br /> FIrm Firm Firm Firm Requested Reyon tldle p <br /> L j �() �� (includes All Raw Data) <br /> RWQCB <br /> REI <br /> Date/ Date/Time Daterrime Date/I'ime (M Dl-s/PQLs/I RACE#) <br /> REI INQIlISIIED BY �—RELIVED BY Special Instructions/Comments <br /> Container Types Key <br /> f_ <br /> 5ignaturt, Si t re <br /> Sequoia Analytical 40 nil VOA I <br /> 612?L 819 Striker Ave,Ste 8 250 nil I PE 2 <br /> Panted Name Prmte�-N4me Sacto,Ca 95834 500 nil LPE 3 <br /> 9 i bA21-9600 <br /> 1 liter HDPE 4 <br /> 1 InnAltn Run Bubel = 500 m]glass 5 <br /> 1 uiI> I IlleE glace 6 <br /> [?tfell tine M s/s ring 7 <br /> ===JI7at� me <br /> 0 <br />