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CHAIN OF CUSTODY 1 LABORAT ice Y ANALYSIS REQUEST FORM 0 <br /> North Market Boulevard,Sacramento,CA 95834 Request No: S Q 4 Q 1010.5 Purchase Order: <br /> sEMC011 (916) 928-3300 FAX (916)928-3341 Lab: Columbia Analytical <br /> Project Name: USA Gasoline Station#65,Lodi, Ca Analysis Requested s <br /> Project Number: 20A41-008.001 <br /> Project Manager: Gowri Kowtha w <br /> Company: EMCON-Pinnacle <br /> Address: 144"A" Mayhew Way <br /> Walnut Creek, Ca 945 U W <br /> Phone: (925)977-9023 0 o <br /> FAX: (925) 977-9030 0 °° <br /> Sampler's Signature: z <br /> REMARKS <br /> Sample LAB Sample 1 Container Types <br /> I.D. Date, Time I.D. Matrix HCl Preservations <br /> MW-1 3u I i 0water 3 3 <br /> MW-2 Sr y water 3 3 <br /> MW-3 3 water 3 3 <br /> MW-4 3 water 3 3 <br /> N,W-5 /Z t f water 3 3 <br /> MW-6 z water 3 3 <br /> MW-7 ! y water 3 3 <br /> MW-8 CSJ water 3 3 <br /> S-1 water 3 3 <br /> S-2 Z Ia water 3 3 <br /> R I SHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> lJ.44a L REQUIREMENTS X I. Routine Report <br /> Sign Signature Signature Signature 24m 48 txr X Today II. Report(includes DUP,MS <br /> �*+",(-A U`C-tom- Standard(-tal5w-orkingdays) MSD,as required,may be <br /> Print Name Name Printed Name Printed Name Printed Name Provtide Verbal Prelutt <br /> wary Results charged as samples) <br /> A-`L'" C' 9S Provide FAX Pre]urwary Results III.Data Validation Report <br /> Finn / I <br /> Firm /f'� / r Firm Firm Requested Report Date: (includes All Rain Data) <br /> "A' Q '7-1'�S :/D RWQCB <br /> Datefrime .r Datefl"une Datefrime Datefrime (MDLs/PQLsfrRACE#) <br /> RELINQUISHER BY RECEIVED BY Special Instructions/Comments: ,,tt �" (� J Container Types Key: <br /> D V f" �I —I�y Columbia Analytical 40 ml VOA: 1 <br /> Signature Signature Confirm all MTBE hits with 8260. 3334 Victor Court 250 ml LPE: 2 <br /> I <br /> D3, 2� .i D z Santa Clara,Ca 500 ml LPE: 3 I <br /> Printed Name Printed Name f 408-748-9700 1 liter HDPE: 4 <br /> Bernadette Cox 500 ml glass: S ; <br /> Firm Firm 1 liter glass: 6 <br /> 20 s/s ring: 7 <br /> Datefrime Date/Time <br />