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i <br /> 4080 PIKE LANE, SUITE C JWAIN-OF-CUSTODY RECORD 91505 <br /> IGTELCONCORD, CA 94520 AND ANALYSIS REQUEST <br /> (510) 685-7852 <br /> (800)423-7143 ANALYSIS REQUEST OTHER <br /> lA!°1A 10lI F� NC <br /> Company Name Phone# (sin) 6 7 i--,�,(-7 <br /> x FAX# �S q Elp m El <br /> Site Location f m _ ❑ <br /> Company Address 4457 QoP# Ct[�e I�w� ��5 /naf>�l '�`"`� m ❑ ❑ <br /> Project Manager Client Project ID (#)oElV <br /> �tao�ola2! 61c�3 ❑ o v N W � m < a <br /> p 4l' m ° ❑ N ❑ ❑ z z p o Q ❑ <br /> I attest that the proper meld sampling Sampler ame(PrinJ/�� /�I ° 0 m o 0 ❑ ❑ o <br /> procedures were used during the �'�} ,` A o d D o a N ❑ ❑ C N ❑ a c~n n o <br /> collection of these sam les Marl(r 0 o `� Ln a o � N a a s ❑ a j <br /> o m LL m rn m a ago eco ❑ m m ❑ O c CJ o N <br /> Matrix Method c0 ❑ d o <br /> Sampling o b � e a ❑ o w a a � ❑ ❑ ma y a N ❑ <br /> c Preserved W a y ❑ m m ❑ [} <br /> Field G7EL W - s <br /> z ❑ m °' $ ❑ ❑ ❑ a a ❑ g m N <br /> Sample Lab# a u, o $ �' N CD 4 � 0 x d <br /> F aC C7 c cC ca O ,� Q a m ca m O a M <br /> ID (Lab Use O� M 0 i ¢? _ ►"'- "' w w a D I W a a a a a a a a , o, <br /> ` only c� a o Q �, oc v z Z W 8 a M — a a a n. a a o a a a U a a o J r{ <br /> 3 rn a cn a o x x x Zh O 0 m m x x 0 i- w w w w w w w w w F- w 0 � O 0 <br /> c i m <br /> " <br /> CAA <br /> f 1 <br /> r y,L <br /> 'j <br /> ILL <br /> T <br /> TAT Special Handling SPECIAL DETECTION LIMITS REMARKS P. to f I n,' / o <br /> Priority(24 hr) C] GTEL Contact (.A T Sot) INF hr, C 4 C66 Cc/n,k G <br /> Expedited(48 hr) ❑ Quote/Contract# +� ° <br /> 7 Business Days ElConfirmation#10 PS t 00 F �FF r� 400 ov, C <br /> Ocher SPECIAL REPORTING REQUIREMENTS Lab Use Only Lot# Storage Location <br /> Business Days ❑ PO # ��O CJ a 2-52QA/0C Level � � ' <br /> Blue❑ CLP❑ Other❑ _ FAX❑ Work Order# <br /> Relinquished by Sampler Date Time Rect <br /> 6y 1' <br /> CUSTODY <br /> RECORD Relinquished by Date Time Received by <br /> Relinquished by Date Time Received by Laboratory <br /> 0 Waybill# <br /> I � <br />