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CHAIN OF CUSTODY 1 LABORATORY ANALYSIS REQUEST FORM <br /> 1433 North Market Boulevard,Sacramento,CA 95834 Service Request No: Purchase Order: <br /> E11MC011 (916)928.3300 FAX(916)928.3341 Lab: Columbia Analytical <br /> Project Name:USA Gasoline Station M Lodi,Ca Analysis Requested <br /> Project Number: 20A41-008.001 <br /> Project Manager. Gowri Kowtha W <br /> Company: EMCON-Pinnacle <br /> Address: 144 A Mayhew Way c W <br /> Walnut Creek,Ca 94596 J <br /> Phone: (925)977-9023 o r: <br /> FAX: (925)977-9030 <br /> Sampler's Signature: x o 0 <br /> z °0° REMARKS <br /> Sample Sample 1 Container Types <br /> I.D. Date Time I.D. Matrix HCl Preservations <br /> MW-1 Z1 ` 1337 water 3 3 <br /> MW-3 IINN f Z51 water 3 3 <br /> MW-4 water 3 3 <br /> MW-5 water 3 3 <br /> MW-6 water 3 3 <br /> MW-7 water 3 3 <br /> MW-8 tj 01 water 3 3 <br /> i <br /> RELINQUISHED BY RECEIVED BY RELINQUISHED BY RECEIVED BY TURNAROUND REPORT REQUIREMENTS <br /> REQUIREMENTS X 1. Routine Report <br /> Signature Signature Signature signamm 24rr 49 her X 10day H. Report(includes DUP.MS <br /> swriud(1415 WO&M days) MSD,as required,may b-- <br /> Printed <br /> ePrinted Name Printed Name Printed Name Printed Nam Provide Ve&d Mkobw Raelts cloned as samples) <br /> Provide FAX Paimimuy Rau1n III.Data Validation Report <br /> Firm Firm Firm Firm Requested Report nate: (nndudes All Raw Data) <br /> RWQCB <br /> Date/Thne DaW13me DWrime Date(I'ime MDLs1PQLs/IRACE#) <br /> RELINQUISHED BY RECEIVED BY Special Instructions/Comments: Container Types Key: <br /> Columbia Analytical 40 ml VOA: I <br /> sigrtatum Signature 3334 Victor Court 250 ml LPE: 2 <br /> Santa Clara,Ca 500 ml LPE: 3 <br /> Printed Name Printed Name 408-748-9700 1 liter HDPE: 4 <br /> Bernadette Cox 500 mi glass: 5 <br /> Film Finn 1 liter glass: 6 <br /> 2x6 s1s ring: 7 <br />