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i eStHmerica Irvine Chain of Custody Record �l 7 TestAmedca <br /> 17461 Derian Ave 0 5 1 79 4 <br /> Suite 100 <br /> THE LEADER IN ENVIRONMENTAL TESTING <br /> Irvine, CA 92614 TestAmerica Laboratories, Inc. <br /> Phone: 949.261.1022 Fax: Regulatory Program: ❑DW ❑NPDES ❑RCRA ❑Other: TAL-8210 t0773) <br /> Client 9ontact Project Manager: Site Contact: I Date: COC No: <br /> Company Name: _f .: i Tel/Fax: Lab Contact: Carrier: of COCs <br /> Address: fes . Analysis Turnaround Time Sampler: <br /> CilyfStateizip; f ; 74 E] CALENDAR DAYS ❑ WORKING DAYS For Lab Use Only: <br /> �+ Walk-in Client: <br /> Phone: TAT if different from Bebwf f Z <br /> Fax: ❑ 2 weeks Z \ Lab Sampling: <br /> Project Name! ❑ 1 week <br /> Site: ❑ 2 days ; �y .Job/SDG No.: <br /> PO# ❑ 1day E <br /> to <br /> Sample m g <br /> Type d c <br /> Sample Sample (c=Comp, #of <br /> Sample Identification Qate Time G=Grab) M1 atrifc co/nt. Sample Specific Notes: <br /> Preservation Used: t=Ice, 2=HCl; 3=H2SO4; 4=HNO3; 5=NaOH;6=Other <br /> Possible Haxard Identifica[fo»: Sample Disposal(A fee may be assessed ff samples are retained longer than i month) <br /> Are any samples from a listed EPA Hazardous Waste? Please List any EPA Waste Codes for the sample in the <br /> Comments Section if the lab is to dispose of the sample. <br /> l.1 Non-Hazard ❑Flammable n LJ Skin Irritant Polson B Unkn ❑Return to Client ❑Disposal by Lab El Archive for Months <br /> Special Instructions/QC Requirements&Comments: <br /> Custody Seals Intact: ❑ Yes ❑ No Custody Seal No.: Cooler Temp.('C):Obs'd: Cored: Therm ID o.: <br /> Relinquished �G � Company- Date1"fi Received � Company: Da�� {b O <br /> //!! w '-l/VCX/1 �n 1� l7 v 17 <br /> RelinquI d by: Company: ateMme: Received by: Company, Date/Tli e: <br /> Relinquished by: Company: Date/Time: Received in Laboratory by: Company: DateMme: <br />