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1 <br /> M�®RE TWI�H,�� CHAINOFCUSTODY/ANALYSIS REQUEST <br /> ��2.. <br /> s _ , WORK ORDER #: � <br /> 1 PAGE OF o <br /> ANALYTICAL CHEMISTRY DIVISION <br /> CALIFORNIA ELAP CERTIFICATION M 1371 <br /> REPORT TO: ❑INVOICE TO: ❑REPORT COPY TO: REPORTING: <br /> 1 ATTENTION: ATTENTION: ❑ STANDARD PRINTED REPORT <br /> J=. �Rsw1J ❑ WRITE-ON (STATE FORM) <br /> NAME: NAM-z: <br /> 1 G�o��1 s,r5U1. TS GEOTRACKER/COELT(LUfT) <br /> ADDRESS: ADDRESS: ❑ PDF ❑SPREADSHEET <br /> 31� sz9 VALL �TL *900 ❑ County DHS: <br /> 1 WAdvU=,o 2n-vA G:y 95--kLlZ ❑ En°ilrDnmental Health Agency: <br /> PHONE:�,I 11//''\ Q q p PHONE: <br /> i 4LoJ "� & L�'�U <br /> FAX: FAX: F1 OTHER: <br /> SAMPLE INFORMATION SAMPLE TYPES: PROJECT INFORMATION <br /> SAMFIED BY(PRINT): SOLID: CONTRACT/P.O.NO. <br /> .JASN f.��✓zT f?,ta� �¢,U.., BS- BIOSOLID 3 O'S}L'IZ <br /> 1 SIGNATURE: CR-CERAMIC PROJECT: <br /> C:>A SL- SOIL/SOUD �O zaAc2 �' _ WA6N <br /> LIQUID: PROJECT NUMBER: <br /> ❑ PUBLIC SYSTEM ❑ROUTINE DW- DRINKING WATER 51183-06-01 <br /> ❑ PRIVATE WELL ❑ REPEAT GW-GROUND WATER PROJECT MANAGER: <br /> 1 ❑ OTHER ❑ REPLACEMENT OL-OIL (�g:ryN 5-,6wp <br /> SF-SURFACE WATER ANALYSIS REQUESTED <br /> TURN AROUND TIME: ❑ RUSH,DUE ON: ST-STORM WATER o <br /> STANDARD WW-WASTE WATER <br /> NOTES ON RECEIVED CONDITION: 1dl 2 <br /> 1 , A LJ CUSTODY SEAL(S)BROKEN E3SAMPLE(S)DAMAGED <br /> B ❑ON ICE ❑AMBIENT TEMP. ❑INCORRECT PRESERVATION <br /> U <br /> S r U <br /> E , LAB USE <br /> 1 CLIENT SAMPLE ID DATE TIME TYPE <br /> 1 Z W.3 <br /> 1035 <br /> 1 M w-I I215 L' <br /> 1 <br /> 1 COMMENTS/ADOmONAL INSTRUCTIONS: X <br /> 1 <br /> 1 RELINQ HED BY COMPANY DATE TIME RECEIVED BY COMPANY' <br /> „c II O Ste. <br />