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CHAIN OF CUSTODY 1 LABORAARY ANALYSIS REQUEST FORM <br /> a&33 North Market Boulevard,Sacramento,CA 95834rvic R - <br /> e agues[No: Purchase Order: <br /> IMC011 (916)928-3300 FAX(916)928.334I Lab: Columbia Analytical <br /> Project Name: USA Gasoline Station#65,Lodi,Ca Anal sis Requested <br /> Project Number: 20A41-008.001 <br /> Project Manager: Gowri Kowtha W <br /> Company: EMCON-Pinnacle <br /> Address: 144 "A" Mayhew Way W <br /> Walnut Creek,Ca94 U _ <br /> Phone: (925)977.9023 0 <br /> FAX: (925)977-9030 L 9-0 <br /> Sampler's Signature: x c <br /> � ° <br /> � U � <br /> Sample p z REMARKS <br /> Sample 1 Container Types <br /> I.D. Date, Time I.D. Matrix ow HCI Preservations <br /> MW-1 01 q3k water 3 3 <br /> MW-2 1 water 3 3 <br /> MW-3 water 3 3 <br /> MW4 water 3 3 <br /> MW-5 ZIT water 3 3 <br /> MW-6 t f water 3 3 <br /> MW-7 (W water 3 3 <br /> MW-8 -oma water 3 3 <br /> S-1 r water 3 3 <br /> S-2 Z water 3 3 <br /> R T�FD BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X 1. Routine Report <br /> Si Signature <br /> Signature REQUIREMENTS <br /> 24M 48 hr Xi IOAsy IG Repos(includes DUP.MS <br /> 3-M-7( tats ry&; a+ys) MSD,as required,may be <br /> Print Name Printed Name Printed Name P�Vmba <br /> Printed Name muResWp charged as samples) <br /> Provide FAX PMbmszy Remits III.Data Validation Report <br /> Frrn <br /> Finn <br /> l f� Firm Regmmd Repan Dne: (includes A11 Raw I7eta) <br /> 7 <br />� DatrJlime Date/Ctme Date/Time DatrJl;me RWQC$ <br /> h RELINQUISHED BY RECEIVED BY Special irLctructlotsslCommeatx (MDL%RQLs(IRACE#}Container Types Key: <br /> ey: <br /> Columbia Analytical 40 ml VOA: I <br /> sip" a Confirm all MTBE hits with 5246. 3334 Visor Court 250 ml LM: 2 <br /> Printed Name Printed Nemo Santa Clara,Ca 540 ml LPE: 3 <br /> 408-748-9700 1 liter HDPE: 4 <br /> Firm Free <br /> Bernadette Cox 500 ml glass: 5 <br /> I liter glass: 6 <br /> Datell'ime DateJl`ttne 2x6 sls ring: 7 <br />